■It'.';'  •^'^:  -7.»?'*  ^--.7 ^•' '*•»'••< 


■   .iff:';:-'  i  i :  r: 

'  .      -..1  '  iii':<'>)L;4|i  '.1,1. 


'V 


[.:•    '^^. 


.^»!i. 


> '..fif \y/' i?>v  ■'•;•■ 


INJURIES  AND   DISEASES 


OF 


THE    JAWS 


BY  THE   SAME  AUTHOR. 


A  Course  of  Operative  Surgery.  With  20  Plates 
drawn  from  Nature,  by  M.  L^veille,  Coloured. 
Second  Edition,  large  8vo. 

Practical     Anatomy :    A  Manual   of  Dissections. 

With  329  Wood  Engra-ving^s.    Eighth  Edition,  edited 
by  William  Anderson,  F.E.C.S.,  8vo. 

A  Manual  of  Minor  Surgery  and  Bandaging,  for 

the  Use  of   House- Surgeons,   Dressers,  and  Junior 
Practitioners.   With  158  Engravings.    Tenth  Edition. 
.  8vo. 

The    Student's    Guide    to    Surgical    Diagnosis. 

Second  Edition.     8vo. 

Clinical  Lectures  on  Surgical  Subjects.    8vo. 


INJURIES  AND  DISEASES 


THE    JAWS 


THE  JACKSONIAN  PRIZE  ESSAY  OF  THE  ROYAL  COLLEGE 
OF  SURGEONS  OF  ENGLAND,  1867. 


CHRISTOPHER    HEATH,  F.R.C.S., 

HOLME    PROFESSOR   OF    CLINICAL   SURGERY   IN    UNIVERSITY   COLLEGE,    LONDON,    AND 

SURGEON    TO   UNIVERSITY   COLLEGE    HOSPITAL;    CONSULTING 

SURGEON    TO   THE  DENTAL   HOSPITAL. 


FOURTH  EDITION. 

WITH  NUMEROUS  WOOD  ENGRAVINGS. 


EDITED    BY 

HENRY    PERCY    DEAN,  M.S.,  P.R.O.S. 

ASSISTANT  SURGEON    TO   THE   LONDON    HOSPITAL  ; 
SURGEON   TO   THE   NORTH-EASTERN    HOSPITAL   FOR   CHILDREN 


PHILADELPHIA: 
BLAKISTON,     SON     &     CO. 

1012     WALNUT     STREET. 
1894. 

{All  rights  of  Translation  and  Reproduction  arc  rese>-i<ed.\ 


H3S 


PREFACE  TO  THE  FOUHTH  EDITION. 


In  preparing  a  fourth  edition  of  this  book  I  have  been  able 
to  avail  myself  of  the  able  assistance  of  Mr.  Percy  Dean,  a 
former  distinguished  student  of  University  College,  and  now 
Assistant-Surgeon  to  the  London  Hospital.  Mr.  Dean  has 
had  occasion  to  modify  the  arrangement  of  some  of  the 
material  so  as  to  bring  it  into  more  correct  relation  with 
modern  pathology,  whilst  I  have  exercised  a  general  super- 
vision, and  have  endeavoured  to  incorporate  the  experience 
of  another  ten  years  of  active  professional  life. 

Cheistophee  Heath. 

36  Cavendish  Square, 
Fehriiarij  1894. 


TABLE    OF    CONTENTS. 


CHAP.  PAGES 

I.   FEACTUEK   OF   THE   LOWER  JAW          .           .                      .           .  I —      8 

II.   COMPLICATIONS  OF  FRACTURE   OF   THE   LOWER  JAW       .  9—  2$ 

III.  TREATMENT   OF   FRACTURED   LOWER  JAW          .           .  26 —  42 

IV.  FRACTURE   OF   THE   UPPER  JAW 43 —   52 

V.   GUNSHOT  INJURIES  OF  THE  JAWS 53—   ?! 

VI.   DISLOCATION   OF  THE   LOWER   JAW 72—   88 

VII.   INFLAMMATORY  DISEASES,  PERIOSTITIS,  AND  ABSCESS    .  89— 102 

VIII.   NECROSIS   OP   THE   JAWS IO3— II7 

IX.  REPAIR  AFTER  NECROSIS;  TREATMENT    ....  I18 — 129 

X.    HYPEROSTOSIS      .........  I30 — I4O 

XI.   DISEASES    OF   THE  ANTRUM I4I  — 169 

XII.   CYSTS    OP    THE    JAWS  ;    DENTAL   CYSTS ;    DENTIGEEOUS 

CYSTS 170 — 209 

XIII.   ODONTOMATA  AND     CERTAIN    IRREGULARITIES  OF   THE 

TEETH 210 — 225 

XIV.   DISEASES  OP  THE  GUMS  ;   EPULIS ■  226 — 248 

XV.   TUMOURS  OP   THE   PALATE 249 — 256 

XVI.  NON-MALIGNANT   TUMOURS  OF    THE  UPPER  JAW    .           .  257 — 280 

XVII.  MALIGNANT   TUMOURS   OF  THE   UPPER  JAW    .           .           .  28 1 — 302 
XVIII.   DIAGNOSIS     AND      TREATMENT     OF    TUMOURS    OF    THE 

UPPER  JAW 303 — 315 

XIX.  NON-MALIGNANT  TUMOURS  OF  THE  LOWER  JAW             .  316—329 

XX.  MALIGNANT   TUMOURS   OF  THE   LOWER  JAW   .          .          .  33O — 359 
XXI.   DIAGNOSIS    AND     TREATMENT      OF      TUMOURS   OF    THE 

LOWER  JAW 360—369 

XXII.   PARASITIC  DISEASES   OF   THE  JAWS            ....  370— 374 

XXIII.  DISEASES  OF   THE   TEMPORO-MAXILLARY  ARTICULATION  375^388 

XXIV.  CLOSURE   OP   THE  JAW 389— 4I4 

XXV.   DEFORMITIES   OF  THE  JAWS                415— 420 


ILLUSTEATIONS. 


Fig. 
I. 
2. 

3- 

4- 


9- 
lo. 
II. 

12. 

13- 
14. 

15- 
16. 

17- 
18. 
19. 
20. 
21. 
22. 

23- 
24. 

25- 

26. 
27. 
28. 
29. 
30. 

31- 
32. 
33- 
34- 
35- 
36. 
37- 
38. 
39- 
40. 
41. 
42. 


Fracture  with  overlapping         ....    after  Malgaigue 

„         with  displacement 

,,  of  condyles  and  coronoid  process  .  .  Fergusson 
Fracture  united  at  an  angle,  from  St.  George's 

Hospital  Museum Original 

„  „  (Hepburn) 

Displacement  with   fibrous  union      .         .         .    after  llalgaigne 
Ununited  fracture  after  gunshot  injury    .         .         .     Cox  Smith 

)1  >)  5)  •  • 

Fibrous  union,  from  University  College  Museum 
Four-tailed  bandage  for  lower  jaw 
Hamilton's  apparatus 
Gutta-percha  splint  . 


Hammond's  wire  splint 


Model  showing  displacement  of  fragments 
The  same  reduced  with  Hammond's  splint 
Gunning's  interdental  splint 


Angle's  method  of  acting  on  the  teeth 


Hay  ward's  mouth-piece 
Lonsdale's  apparatus 
Thomas's  wire-suture 

Fracture  of  upper  jaw 

Plate  for  ditto    .... 

Gunshot  injury  of  jaw 

Silver  chin         .... 

Dissection  after  loss  of  jaw 

Gunshot  injury  of  face 

Dislocation  of  lower  jaw    . 

))  ))  •         • 

Dissection  of  dislocation  of  lower  jaw 
Dislocation  of  lower  jaw    . 


Stromeyer's  forceps 

Necrosis  of  intermaxillary  bones 


Original 

after  Hamilton 
Erichseii 

.". 

Original 

Newland-Pedley 
Gunning 

5» 
)) 

Angle 


B.  Hill 
Erichsen 

Salter 
DeboiU 


Astley  Cooper 

after  Malgaigne 

Original 

Fergusson 

R.  W.  Smith 

J.  Cou2}er 

after  Goffres 

.  Bryant 


4 
5 
7 

15 
15 
IS 
18 


24 

27 
27 
28 
28 
29 
30 
31 
31 
33 
34 
35 
35 
36 
37 
38 
39 
41 
41 
44 
45 
62 

63 
63 
65 
74 
76 

77 
7^ 
79 
81 
86 
113 


ILLUSTRATIONS. 


Fig. 
43. 

44- 
45- 
46. 

47- 


Necrosis  of  lower  jaw 
„        of  tipper  jaw 
Portrait  of  patient  after  removal 
Eepair  after  phosphorus-necrosis 


48.  Hyperostosis,  portrait 


49. 
SO. 
51- 
52. 
53- 
54- 
55- 
56. 
57- 
58. 

59- 
60. 
61. 
62. 

63- 
64. 

65- 
66. 
67. 
68. 
69. 
70. 

71- 
72. 

73- 
74. 
75- 
76. 

77. 
78. 

79- 
80. 
81. 
82. 

83. 
84. 

85. 
86. 
87. 
88. 
89. 
90. 
91. 
92. 

93- 

94. 

95- 
96. 

97. 

98. 

99. 

100. 

lOI. 


,,  ,,  after  operation     . 

„  .„  (Author) 

„  .,  cast  of  palate 

„  „  section  of  jaw 

Antrum  Highmorianum     .... 
„  „  of  normal  size 

„  ,,  subdivided  (with  perforation) 

Distension  of  antrum         .... 
Stevenson's  oral  lamp        .... 
Deformity  from  distended  antrum    . 
Cyst  of  antrum  (W.  Adams) 


Cyst  of  teeth 


Cyst  of  lower  jaw 


Inverted  tooth  . 
Dentigerous  cyst  (Fearn" 


„  „  (Underwood)    . 

Calcified  cyst  (Cartwright) 
Patient  with  dentigerous  cyst  (Author) 
Dentigerous  cyst       .... 
Skeleton  of  cyst  of  lower  jaw  (St.  Bartholomew) 
Multilocular  cyst  of  lower  jaw  . 

Large  cystic  sarcoma  of  lower  jaw  (Author) 

Patient  three  months  after  removal  . 

Cast  of  multilocular  cysts 

Multilocular  cystic  tumour 

Recurrent  epithelioma 

Odontoma 


,,  (Fergusson) 

,,  (Author) 

II  'I 

Misplaced  tooth 


Hypertrophy  of  gum  (MacGillivray) 
„  ,,  (Author) 

)»  >j  >>  •        • 

Hypertrophy  of  alveolus     „  .         . 

Papillary  tumour  of  gum  (Fergusson) 
„  ,,       of  palate  (Cock)   , 

,,  ,,  ,,  section  (Cock) 

Epulis  (Hutchinson)  .... 


Toy 
Hart 

') 
Savory 

after  Howsldp 
Fergusson 


Fergusson 

Stevenson 

Fergusson 

Original 

after  Giraldes 

Original 


Original 


Testuit 

Cattlin 


Fergusson 

>> 

Tomes 
Original 

jj 

Forget 
Original 

Cattlin 
Original 

Forget 

Original 

B.  Adams 

Cusach 
Original 


Forget 
Salter 

Tomes 

Forget 
Original 

11 
Forget 

Original 


Salter 


Original 


115 
117 
117 
121 
121 
131 
13s 
135 
136 
137 
137 
142 
142 

143 
148 

152 
159 
161 
161 
175 
175 
175 
178 
179 
179 
184 
i8s 
185 
187 
188 
188 
189 
193 
195 
196 
197 
201 
201 
204 
206 
207 
211 
212 
212 
213 

215 
217 
219 
219 
224 
224 
228 
229 
229 
230 
233 
234 
234 
235 


FlCr. 

I02. 
103. 
104. 
105. 
106. 
107. 
108. 
109. 
1 10. 
III. 
112. 

113- 

114. 

115- 
116. 
117. 
118. 
119. 
120. 
121. 
122. 
123. 
124. 
125. 
126. 
127. 
128. 
129. 
130. 

131- 
132. 

133- 
134- 
135- 
136. 
137. 
138. 

139- 
140. 
141. 
142. 

143- 
144. 

145- 
146. 
147. 
148. 
149. 
150. 
151. 
152. 
153- 
T54. 
155- 
156. 

157- 
158. 
159- 
160. 


ILLUHTIIATIONS. 

Epulis,  myeloid  (Hutchinson) 
,,       giant-celled  (Wilkes)     . 
,,       (Author) 

1?  n  ... 

„      case  of  Mary  Griffiths   . 

i>  I)  ))       •         • 

Cross -cutting  forceps 

J)  !>  ■  • 

Bone-forceps     .... 

5>  .... 

Epithelioma  of  gum  . 
Sarcoma  of  hard  palate  (Author) 
Fibrous  tumours  of  upper  jaw  . 
Ann  Struther  before  operation 

,,         „         after  operation   . 
Mrs.  Frazer       .... 
Large  recurrent  enchondroma  (Author) 
Osseous  tumour  (Dupuytren)     . 

»  „        (Fergusson) 

(Duka) 
Myeloid  of  upper  jaw 
Round-celled  sarcoma  (Craven) 

)5  ))  •  •  • 

Double  round-celled  sarcoma        (Author) 
Round-celled  sarcoma  of  both  jaws 
Epithelioma  of  antrum  „ 

Incisions  for  removal  of  upper  jaw 


Original 


Liston 


Fergusson 


Original 
Liston 


Oriqinal 
after  V.  de  Cassis 

)> 
Original 
Fathological  Society 
Canton 
Original 


Saw  for  jaw       ..... 

Lion  forceps      ..... 

Second  stage  of  removal  of  upper  jaw 

Third  stage  ,,  ,, 

Patient  after  removal  of  jaw  and  eyeball  (Author) 

Fibrous  tumour  of  lower  jaw  (University  College) 

,,  „        between  plates  (King's  College) 

Large  fibrous  tumour  of  lower  jaw  (Fergusson) 
Upper  jaw  of  same  patient  .... 
Recurrent  enchondroma  of  lower  jaw 

I)  )>  ))  •         •         ■ 

Ivory  exostosis  of  lower  jaw  (South) 

,,  „  „         (Author) 

Myeloid  tumour  of  symphysis  (Craven)    . 

,,  „  „  section  of . 

Myeloid  tumour  of  both  sides  of  jaws  (Author) 
Patient  after  operation     ..... 
Girl,  after  removal  of  round-celled  sarcoma  of  lower 
Spindle-celled  sarcoma  of  lower  jaw 
Patient,  after  its  removal . 
Spindle-celled  sarcoma  of  lower  jaw 

Chondro-sarcoma  of  lower  jaw  (Author) 

Ossifying  sarcoma  (Author) 

Large  epithelioma  of  lower  jaw  (Author) 

,,            „                after  removal    . 
Epithelioma  of  chin  following  lip  cancer            (Author) 
,,            of  lower  jaw  following  lip  cancer         „ 
„            of  gland  attached  to  jaw       .         .       ,, 
Gag  for  mouth  (Wingrave) 


Liston 
Original 
Fergusson 

Original 


Lawson 
Original 


]aw 


Syme 

)> 
Lawson 

»> 
Original 


XI 

PAGE 
236 
236 

238 
239 
240 
241 
243 
243 
244 

244 
246 

253 
259 
260 
260 
261 
267 
273 
273 
275 
278 
283 
294 
296 

297 
298 
301 

307 
308 

309 
309 
310 
310 
314 
317 
318 
320 
321 

325 
326 

327 
328 
332 
332 

333 
333 
jj5 
339 
339 
342 
343 
344 
347 
351 
352 
356 
357 
358 
362 


Xll 

Fig. 
I6i. 
162. 
163. 
164. 
165. 
166. 
167. 
168. 
169. 
170. 
171. 
172. 

173- 
174. 

175- 
176. 
177. 
178. 
179. 
180. 
181. 
182. 
183. 
184. 
185. 
186. 
187. 


ILLUSTRATIONS. 

Incision  for  removal  of  lower  jaw 

Second  and  third  stages  of  removal  of  lower  jaw 

Actinomycosis  of  the  upper  jaw 

Eheumatoid  arthritis  of  condyles 


,,  ,,  of  glenoid  cavity 

Hypertrophy  of  neck  and  condyle  (McCarthy) 

)»  )i  J)  )> 

Patient  with  hypertrophy  of  neck  (Author) 
Hypertrophy  of  neck  and  condyle        , , 
Treatment  of  temporo-maxillary  arthritis 
Cast  of  misplaced  wisdom-tooth 
Treatment  of  fibrous  ankylosis 
Oral  speculum 
Spiral  spring  speculum 
Closure  of  jaw  by  cicatrices 
Shields  for  application  to  gums  (Clendon) 
Patient  to  whom  these  had  been  fitted  (Holt) 
Closure  of  jaw  by  cicatrices  (Author) 
Eifects  of  Esmarch's  operation 
Closure  of  jaw  and  cicatrix  of  cheek  (Author) 
Effects  of  operations  .... 

Deformity  of  maxilla  from  cicatrix  of  burn 
Deformity  of  jaws  from  cancrum  oris 
Same  patient  after  operation 

,,        ,,       after  second  operation  . 


Orujinal 

I'AGK 

,, 

365 

Albert 

371 

Original 

378 

u 

378 

378 

)J 

379 

)5 

380 

,, 

381 

.J 

382 

'> 

383 

Gooclioillie 

387 

Weiss 

390 

Goodwillie 

392 

') 

393 

„ 

393 

Weiss 

402 

Orifjinal 

402 

„ 

403 

,. 

408 

,, 

409 

„ 

410 

i> 

411 

Tomes 

417 

Harrison 

418 

„ 

419 

)} 

420 

THE   INJURIES  AND   DISEASES 
OF   THE   JAWS. 


CHAPTEE    I. 

FKACTUKE    OF    THE   LOWER    JAW. 

Teacture  of  the  lower  jaw  is  usually  the  result  of  direct 
violence,  though  Professor  Pan  coast  met  with  a  case  in 
which  fracture  of  the  neck  of  the  hone  had  resulted  from  a 
violent  fit  of  coughing,  in  an  old  man  upwards  of  seventy 
years  of  age  (Gross's  "Surgery,"  p.  964).  Blows  received 
on  the  jaw  in  fighting,  or  a  kick  from  a  horse,  are  the  most 
common  causes  of  the  accident ;  but  falls  from  a  height 
upon  the  face  also  produce  some  of  its  most  serious  forms, 
owing  to  the  comminution  resulting.  The  unskilful  appli- 
cation of  the  dentist's  "  key  "  has  been  known  to  cause  a 
complete  fracture  of  the  bone,  but  more  frequently  in  former 
years  than  at  the  present  time,  when  that  instrument  has 
been  almost  entirely  superseded  by  the  forceps. 

Fractures  of  the  alveolus  are  frequently  unavoidable 
during  the  extraction  of  the  molar  teeth,  even  in  the  most 
skilful  hands,  since  the  position  assumed  by  the  fangs  is 
occasionally  such  that  extraction  without  displacement  of 
the  bone  to  some  extent  is  impossible.  These  cases 
ordinarily  give,  however,  little  inconvenience,  since  the 
removal  of  the  alveolus  only  hastens  the  absorption  which 
must  necessarily  ensue  upon  the  removal  of  the  teeth,  unless 
indeed  the  fracture  should  be  so  extensive  as  to  affect  the 
alveoli  of  the  neighbouring  teeth,  in  which  case  exfoliation 

A 


2  FPtACTURE    OF    THE    LOWER    JAW. 

of  a  troublesome  character  may  be  produced.  Unavoidable 
accidents  of  this  kind  have  on  several  occasions  been  made 
the  ground  for  legal  proceedings  against  the  operator ;  but 
most  unfairly  so,  since  the  exercise  of  the  greatest  skill  and 
care  cannot  on  all  occasions  prevent  mishaps  due  to  the 
natural  conformation  of  the  parts. 

Mr.  James  Salter,  in  his  valuable  work  on  "  Dental 
Pathology  and  Surgery"  (1874),  devotes  a  chapter  to  "The 
casualties  which  may  arise  in  the  operations  of  tooth - 
extraction,"  in  which  he  mentions  that,  in  extracting  an 
incisor  tooth  from  the  upper  jaw,  the  whole  mass  of  bone 
corresponding  to  the  intermaxillary  bones  broke  away,  and 
was  merely  held  in  place  by  the  soft  tissues.  Fortunately 
the  bone  reunited  without  an  untoward  symptom.  Mr. 
Salter  also  refers  to  a  case  in  which  a  most  able  operator 
broke  the  horizontal  ramus  of  the  lower  jaw  completely 
through,  in  extracting  a  tooth  with  the  forceps. 

Gunshot  injuries  to  the  face  may  produce  the  most  ter- 
rible injuries  of  the  lower  jaw,  by  splintering  and  removing 
large  portions  of  it ;  and  the  mere  explosion  of  gunpowder 
in  its  immediate  neighbourhood,  as  when  a  pistol  is  fired 
into  the  mouth  by  a  would-be  suicide,  will  produce  a  fracture 
of  the  bone.     (See  chapter  on  "  Gunshot  Injuries.") 

Fractures  of  the  lower  jaw  are  remarkable  from  the  fact 
that  they  are  almost  always  compound  towards  the  mouth, 
though  the  skin  is  rarely  involved  except  in  gunshot  injuries. 
The  fibrous  tissue  of  the  gum  being  very  inelastic,  tears 
readily  when  the  bone  is  broken  across,  and  thus  the  saliva 
and  the  air  come  in  contact  with  the  fractured  surfaces. 
Examples  have  been  described,  however,  where  the  presence 
of  fracture  was  discovered  without  injury  either  to  the  perios- 
teum or  the  mucous  membrane.  When  the  ramus,  or  still 
more  when  the  coronoid  process  or  condyle  is  broken,  the 
bone  is  too  deeply  seated  for  injury  to  extend  into  the 
mouth. 

Position  of  tlic  Fracture. — Fracture  may  occur  at  various 
points  in  the  lower  jaw,  and  the  hocly  of  the  bone  is  that 
most  frequently  injured  (in  fifty-two  out  of  fifty-five  cases 


POSITION    OF    THE    FRACTURE.  3 

recorded  by  Hamilton).  The  fracture  appears  to  occur 
most  frequently  in  the  neighbourhood  of  the  canine  tooth, 
this  position  being  determined  probably  by  the  greater  depth 
of  its  socket,  and  the  consequent  weakness  of  the  bone  at 
that  point ;  but  the  fracture  may  happen  at  any  other  point, 
and  has  been  known  to  occur  exactly  at  the  symphysis  in 
cases  too  old  to  admit  of  separation  of  the  two  portions  of 
the  bone.  Fracture  through  the  symphysis  has  often  been 
described  as  taking  place  chiefly  in  infancy  or  childhood, 
but  in  the  cases  that  have  been  recorded  the  ages  vary  from 
ten  years  to  sixty  years  (average  thirty-two  years,  Hamilton). 
Of  the  fifty-two  cases  of  fracture  of  the  body  recorded 
by  Hamilton,  four  were  perpendicularly  through  the  sym- 
physis and  eighteen  of  the  remainder  were  known  to  be 
oblique,  whilst  of  the  whole  number  no  less  than  sixteen 
were  examples  of  double  and  triple  fractures.  In  thirty 
examples  of  fracture  through  the  body,  not  including  frac- 
ture of  the  symphysis,  the  line  of  fracture  was  twenty 
times  at  or  very  near  the  mental  foramen ;  three  times 
between  the  first  and  second  incisor ;  four  times  behind  the 
last  molar  ;  and  three  times  between  the  last  two  molars. 

The  line  of  fracture,  except  at  the  symphysis,  is  usually 
oblique,  and,  according  to  Malgaigne,  the  thickness  of  the 
bone  is  also  divided  obliquely,  so  that  generally  the  fracture 
is  at  the  expense  of  the  outer  plate  of  the  anterior  fragment 
and  the  inner  plate  of  the  posterior  fragment,  though  this 
rule  is  not  without  exception. 

The  ramus  of  the  lower  jaw  is,  from  its  position  and 
coverings,  much  less  liable  to  injury  except  from  extreme 
violence,  such  as  the  passage  of  a  wheel  over  the  face  or  a 
gunshot  injury,  and  Hamilton  states  that  he  has  seen  only 
two  cases  of  fracture  in  this  situation. 

The  coronoid  process,  owing  to  the  protection  afforded  to  it 
by  muscles,  is  only  occasionally  fractured,  and  is  always 
accompanied  by  the  fracture  of  some  other  part  of  the 
lower  jaw. 

The  condyles  are  fractured  usually  below  the  attachment 
of  the  external  pterygoid  muscles,  and  Malgaigne  divides  these 


4  FEACTURE    OF    THE    LOAVER    JAW. 

fractures  into  two  classes  :  one  class  caused  by  falls  or  blows- 
upon  the  chin,  the  other  class  caused  by  direct  injury  to 
one  side  of  the  face,  and  in  these  latter  cases  there  is 
generally  a  fracture  of  the  body  of  the  lower  jaw  on  the 
opposite  side. 

St/mptoms. — As  a  rule,  these  are  well  marked.  Even  in 
simple  vertical  fracture  of  the  symphysis  the  patient  will  be 
conscious  of  pain  and  slight  grating  on  pressing  the  jaws 
together ;  and  the  surgeon  will  readily  perceive  the  irregu- 
larity of  the  teeth,  due  to  alteration  in  the  level  of  the 
fragments.     The  position  of  a  patient  with  fracture  of  the 

Fig.  I. 


jaw  is  very  characteristic.  He  endeavours  to  support  and 
steady  the  fragments  with  his  hands  in  the  most  careful 
manner,  and  his  anxiety  for  relief  is  often  most  ludicrously 
complicated  by  his  inability  to  explain  by  word  of  mouth 
what  his  ailment  is.  Where  the  laceration  of  the  gum  has 
permitted  displacement  of  the  fragments,  manipulation  on 
the  part  of  the  surgeon  is  unnecessary  for  the  establishment 
of  the  diagnosis ;  but  when  any  doubt  exists  he  should  grasp 
the  jaw  on  each  side,  with  the  forefingers  iutroduced  into 
the  mouth,  and  will  have  no  difficulty  in  perceiving  the 
movement  and  crepitus  between  the  fragments. 

Fracture  of  the  hody  of  the  lower  jaw  may  occur  in  one 
or  several  places.  When  a  single  fracture  occurs  on  one 
side  of  the  median  line,  the  small  fragment  is  liable  to  dis- 
placement by  muscular  action,  being  drawn  outwards  and  at 
the  same  time  a  little  forwards,  so  as  to  overlap  the  larger 


SYMPTO:\IS    OF    FKACTUltE,  •  5 

fragment.  This  is  due  to  the  action  of  the  temporal  and 
masseter  muscles,  but  principally  to  the  latter,  and  is 
favoured  by  the  generally  oblique  direction  of  the  line  of 
fracture  and  consequent  tendency  of  the  bones  to  override, 
as  pointed  out  by  Malgaigne  (Fig.  i).  An  instance  of  the 
■obliquity  of  the  fragment  being  reversed  is  given  by  Dr. 
Kinloch  in  the  American  Journal  of  Medical  Sciences  for 
July,  1859.  Here  the  patient,  who  was  fifty  years  of  age, 
met  with  a  compound  fracture  of  the  right  side  of  the 
jaw,  in  front  of  the  masseter  muscle.      "  The  line  of  frac- 


ture divided  the  bone  obliquely  through  its  thickness,  the 
obliquity  being  at  the  expense  of  the  external  plate  of  the 
small  posterior  fragment,  and  of  the  internal  plate  of  the 
large  or  anterior  fragment."  Hamilton  has  seen  two  cases 
in  which  the  posterior  smaller  fragment  was  internal  to  the 
anterior  larger  fragment. 

In  double  fractures  of  the  body  of  the  jaw,  one  being  on 
each  side  of  the  median  line,  the  displacement  is  necessarily 
greater,  since  the  muscles  attached  to  the  chin  tend  to  draw 
the  central  loose  piece  downwards  and  backwards  towards  the 
hyoid  bone,  whilst  both  lateral  portions  are  drawn  forwards 
and  outwards,  as  described  in  the  previous  paragraphs.  When, 
as  is  probably  the  case  in  most  instances  of  the  kind,  the 
obliquity  of  the  fracture  is  the  same  on  the  two  sides — i.e., 
at  the  expense  of  the  outer  surface  of  both  extremities  of 
the  central  fragment,  no  difficulty  is  experienced  in  reducing 


6  FEACTUKE    OF    THE    LOWEE    JAW. 

the  fracture,  and  it  is  only  necessary  to  see  that  the  posterior 
fragments  are  sufficiently  approximated  to  the  central  por- 
tion ;  but  when  the  obliquity  is  different  on  the  two  sides, 
the  fracture  being  at  the  expense  of  the  outer  plate  of  the 
posterior  fragment  on.  the  right  side,  and  the  reverse  on  the 
left  side  (consequent,  no  doubt,  upon  the  blow  having  been 
struck  to  the  left  of  the  median  line),  it  is  obvious  that 
o-reat  difficulties  will  be  encountered  both  in  reducino;  and 
maintaining  the  apposition  of  the  fragments  (Fig.  2). 

Fracture  of  the  ramus  is  usually  produced  by  some 
crushing  force,  such  as  the  wheel  of  a  carriage,  as  in  a  case 
recently  under  my  care,  and  the  bruising  of  the  soft  parts  is 
therefore  considerable.  But  little  displacement  ordinarily 
occurs,  owing  to  the  deep  situation  of  the  bone,  and  the  fact 
that  it  is  well  supported  on  each  side  by  the  masseter  and 
internal  pterygoid  muscles.  In  the  case  alluded  to  under 
my  own  care,  the  patient  was  a  boy  of  twelve,  and  the  pro- 
minent symptom  was  the  projection  of  the  lower  incisors 
beyond  the  upper  jaw,  with  slight  displacement  towards  the 
injured  side.  But  when  there  is  much  laceration  and  loss 
of  substance,  as  in  gunshot  injuries,  the  upper  fragment  is 
apt  to  be  tilted  forward  by  the  temporal  muscle,  as  was 
noticed  in  a  case  under  my  own  care. 

Fracture  of  the  nech  of  the  condyle  is  not  so  rare  an  acci- 
dent as  has  been  stated  by  some  authors,  judging  from  the 
number  of  museum  specimens  of  the  accident  which  exist. 
Fig.  3,  from  Sir  William  Fergusson's  "  Practical  Surgery,-" 
shows  very  well  the  ordinary  appearance  of  the  fracture, 
though  in  some  specimens  the  line  of  fracture  is  more 
obliquely  placed.  The  cause,  in  all  the  recorded  cases,  is 
the  same — viz.,  a  fall  from  a  considerable  height.  The 
symptoms  are  obscure,  there  being  pain  and  difficulty  of 
movement  on  the  affected  side,  and  crepitus  perceived  by 
the  patient.  The  condyle  is  drawn  inwards  and  forwards  by 
the  pterygoideus  externus,  as  can  be  ascertained  by  passing 
the  finger  into  the  mouth,  and  the  jaw-bone  is  apt  to  be- 
come slightly  displaced,  so  that  the  chin  is  turned  toiuards 
the  affected  side  and  not  from  it,  as  is  the  case  in  dislocation. 


FKACTUEE    OF    NECK    OF    CONDYLE.  7 

Dr.  Fountain  lias  recorded  in  the  Ncio  Yurk  Medical 
Journal,  January,  i860,  a  case  of  fracture  of  the  neck  of  the 
left  condyle  with  fracture  through  the  body  on  both  sides, 
caused  by  a  idl\  from  a  height,  in  which  the  following  symp- 
toms were  present.  The  jaw  was  displaced  backwards  and 
laterally  on  the  left  side — a  displacement  which  was  tem- 
porarily rectified  as  long  as  traction  was  made  at  the 
symphysis,  which  the  connections  of  the  middle  fragment 
with  the  membranous  and  muscular  tissues  permitted.  As 
soon  as  this  traction  was  removed  the  lateral  deformity  was 
reproduced,     and    every   contrivance   resorted    to   failed  to 

Fig.  ^ 


maintain  a  permanent  reduction  of  the  fracture  of  the  neck, 
until  the  upper  and  lower  teeth  were  wired  together  so  as  to 
keep  up  traction  on  the  lower  jaw.  The  case  did  well,  and 
recovered  without  any  deformity. 

When  double  fracture  of  the  neck  occurs,  the  violence 
must  have  been  so  great  as  in  most  cases  to  lead  shortly 
to  fatal  results.  Mr.  Newland  Pedley,  however,  has  recorded 
a  case  of  double  fracture  caused  by  the  passage  of  a  cart- 
wheel, in  which,  three  weeks  after  the  accident,  the  face 
showed  separation  of  the  upper  and  lower  front  teeth  to  the 
extent  of  about  three-fourths  of  an  inch,  and  the  lower  jaw 
receded  greatly.  The  mouth  could  be  opened,  and  there 
was  no  deviation  of  the  median  line.  Examination  of  the 
oral  cavity  revealed  no  fracture  through  the  dental  arches. 
Pressure  over  both  condyles  produced  pain  and  some  slight 
crepitus,  more  marked  on  the  right  side.    (British  Journal  of 


8  FRACTURE    OF    THE    LOWER   JAW. 

Dental  Science,  April  15th,  1889.)  Watson,  of  New  York, 
has  also  recorded  a  case  of  recovery  in  the  person  of  a  man 
who  fell  from  the  yard-arm  of  a  vessel,  breaking  his  thigh 
and  arm  bones  and  both  condyles  of  the  lower  jaw,  (New 
York  Journal  of  Medicine,  October,  1840.) 

Eeduction  of  a  fracture  of  the  neck  of  the  jaw,  should 
complete  displacement  have  occurred,  can  only  be  effected 
by  acting  upon  the  condyle  and  the  jaw  at  the  same  time. 
The  finger  carried  far  back  into  the  mouth  should  throw  the 
condyle  out,  whilst  the  jaw  is  brought  into  its  proper 
relation  with  the  other  hand.  The  fragments  must  then  be 
pressed  firmly  together,  and  against  the  glenoid  cavity,  with 
a  bandage,  liibes,  to  whom  this  plan  is  due,  applied  it 
with  success  (Malgaigne). 

Fracture  of  the  coronoid  'process  is  a  rare  accident.  Thus 
Hamilton  says  that  Houzelot^s  case  is  the  only  one  which  he 
has  found.  Curiously  enough,  however,  he  employs  the  illus- 
tration from  Fergusson's  "  Practical  Surgery  "  a  few  pages 
before,  in  which  a  fracture  of  the  coronoid  process  is  seen. 
The  fragment  would,  no  doubt,  be  drawn  upwards  and 
backwards  by  the  temporal  muscle,  and  might  be  felt  in  its 
new  situation,  though  this  displacement  would  probably  be 
limited  by  the  very  tough  and  tendinous  fibres  which  are  so 
closely  connected  with  the  bone,  forming  the  insertion  of 
the  temporal  muscle,  and  reaching  down  to  the  last  molar 
tooth.  Accordiuo-  to  Sanson,  fractures  of  the  coronoid 
process  do  not  admit  of  union,  but  there  is  no  evidence  in 
support  of  this  view. 

Considerable  inflammation  frequently  follows  a  fracture 
of  the  jaw,  even  of  a  simple  kind,  particularly  if  it  has  been 
neglected  or  overlooked  for  some  hours.  The  face  becomes 
swollen,  and  the  tissues  beneath  the  chin  infiltrated  with 
serum,  which  is  sometimes  converted  into  pus,  giving  rise  to 
troublesome  abscesses.  These  will  be  considered  in  the 
next  chapter  among  the  complications  of  fracture  of  the 
lower  jaw. 


CHAPTER  II. 

C0-MPLICATI0X8  OF  FRACTURE  OF  THE  LOWER  JAW. 

Wounds  of  the  Face  are  rare  accompaniments  of  fracture 
of  the  lower  jaw,  except  in  cases  of  gunshot  injury,  and 
when  found  are  usually  the  result  of  a  kick  from  a  horse. 
The  wound  itself  requires  treatment  on  ordinary  principles, 
and  is  of  little  moment  as  regards  the  fracture  (which  is 
doubtless  ''  compound  "  also  into  the  mouth),  except  as  inter- 
fering with  the  application  of  a  necessary  retentive  apparatus. 
In  a  case  of  extensive  fracture  of  the  lower  jaw,  the  result 
of  a  kick  from  a  horse,  which  I  saw  in  the  Westminster 
HosxDital,  under  ]Mr,  Holthouse's  care,  the  lip  and  chin  were 
extensively  torn ;  and  in  a  case  of  the  late  Mr.  Berkeley 
Hill's,  in  University  College  Hospital,  the  result  of  a  fall, 
the  wound  beneath  the  chin  very  much  interfered  with  the 
application  of  a  modified  form  of  Lonsdale's  apparatus, 
which  it  was  found  necessary  to  employ. 

Haimorrliagr,  beyond  that  resulting  from  laceration  of  the 
gums,  is  rarely  met  with,  since,  although  theoretically  one 
might  imagine  that  the  inferior  dental  artery  w^ould  fre- 
quently be  torn  across,  this  appears  not  to  be  the  case ;  a 
result  due,  no  doubt,  to  the  fact  that  the  elasticity  of  the 
artery  allows  of  its  stretching  sufficiently  to  avoid  rupture. 
In  the  Lancet  of  October  12th,  1867,  a  case  of  fractured  jaw 
is  reported,  under  the  care  of  Mr.  Maunder,  in  which  severe 
haemorrhage  into  the  mouth  occurred  through  a  fissure  in 
the  gum  behind  the  last  molar  tooth.  This  was  effectually 
controlled  by  digital  compression  of  the  carotid  artery,  which 
was  maintained  for  two  hours  and  a  half,  after  which  no 
further  bleeding  occurred.      Secondary  haemorrhage  has  also 


10        COMPLICATIONS    OF    PEACTUEE    OF    THE    LOWEE    JAW. 

been  met  with,  for  Stephen  Smith,  of  New  York,  reports  a 
case  of  double  fracture  in  which  about  a  pint  of  blood  was 
lost  from  the  seat  of  fracture  on  the  twentieth  day.  Injury 
of  the  soft  parts  about  the  jaws  may  give  rise  to  severe 
haemorrhage,  requiring  prompt  treatment ;  thus  Mr.  Lawson 
has  reported  {Medical  Times  and  Gazette,  1862)  a  case  in 
which  it  became  necessary  to  lay  open  the  face  in  order  to 
secure  the  facial  and  transverse  facial  arteries,  torn  by  the 
wheel  of  a  cart,  which  had  fractured  both  the  upper  and 
lower  jaws. 

Mr.  O'Grady  published  a  case  of  compound  comminuted 
fractures  of  both  upper  and  lower  maxillfe,  with  extensive 
laceration  of  the  face,  in  which  tracheotomy  became  neces- 
sary, owing  to  the  urgent  dyspnoea  supervening  a  few  hours 
after  the  accident,  due,  probably,  to  blood  becoming  infil- 
trated into  the  tissues  about  the  base  of  the  tongue.  A  case 
of  death  during  the  administration  of  chloroform,  which 
occurred  at  St.  Bartholomew's  Hospital  in  1882,  seems  to 
have  been  due  to  injury  of  the  larynx  and  extravasation  of 
blood  into  the  muscles  of  the  root  of  the  tongue,  accom- 
panying a  fracture  of  the  lower  jaw  caused  by  a  blow  in 
fighting. 

Dislocation  and  fracture  of  tlie  teeth  are  not  unfrequently 
met  with,  the  former  being  the  direct  result  of  a  blow,  or 
the  consequence  of  a  fracture  running  through  the  socket, 
and  the  latter  the  result  of  direct  violence  ;  or,  in  the  molar 
region  particularly,  in  consequence  of  indirect  force  through 
the  neighbouring  teeth,  or  from  the  teeth  being  forcibly 
driven  against  those  of  the  upper  jaw  (Tomes),  Where 
the  fracture  has  passed  through  the  socket,  the  tooth  may 
fall  between  the  edges  of  the  bone  and  prevent  their  proper 
coaptation,  and  this  should  be  borne  in  mind  when  a  tooth 
is  missing  and  difficulty  is  experienced  in  setting  a  fracture, 
since  Erichsen  mentions  a  case  where  union  was  prevented 
until  the  tooth  was  removed.  In  the  molar  region  the 
crown  of  the  tooth  may  be  broken  off,  one  fang  remaining 
in  situ  and  the  other  dropping  into  the  fracture,  as  was  the 
case  with  a  patient  under  my  own  care.      Teeth   which   are 


DISLOCATION    AND    FEACTUEE    OF    TEETH.  11 

merely  loosened  generally  become  re-attached  and  useful,  and 
should  therefore  not  be  removed. 

I  am  indebted  to  Mr.  Margetson,  of  Dewsbury,  for  a  case 
in  which  double  fracture  of  the  jaw  occurred,  with  disloca- 
tion of  several  of  the  teeth,  and  fracture  of  the  left  second 
bicuspid,  the  crown  of  which  was  embedded  for  more  than 
two  years  in  the  tissues  of  the  mouth,  behind  the  incisor 
teeth.  Mr.  Margetson  removed  the  crown  from  its  abnormal 
position  and  also  the  fang ;  and  both,  together  with  a  plaster 
cast,  showing  very  well  the  deformity  resulting  from  the 
fracture  of  the  jaw,  are  in  the  Museum  of  the  College  of 
Surgeons. 

The  front  teeth  may  be  broken  off,  with  the  portion  of 
the  alveolus  containing  them,  by  a  horizontal  fracture,  either 
alone  or  in  combination  with  a  vertical  fracture  through  the 
thickness  of  the  bone.  A  specimen  in  University  College 
shows  a  vertical  fracture  through  the  symphysis,  with  a 
horizontal  fracture  running  through  the  alveolus  on  the 
right  side,  separating  the  portion  containing  the  right  lateral 
incisor,  the  canine,  and  first  bicuspid  teeth.  Such  a  frag- 
ment may  be  made  to  re-unite  if  treated  at  once,  but  when 
some  days  have  elapsed,  and  the  fragment  is  only  attached 
by  a  portion  of  gum,  removal  must  necessarily  be  performed. 
A  case  of  the  kind  was  recently  under  my  own  care,  in  the 
person  of  a  man,  aged  sixty,  who  had  had  a  blow  on  the  left 
side  of  the  jaw  six  days  before  I  saw  him.  I  found  a  loose 
piece  of  alveolus  three-quarters  of  an  inch  in  length,  and 
containing  the  left  incisors  and  canine  teeth,  which  was 
merely  held  by  a  portion  of  gum,  there  being  no  other 
injury  to  the  jaw.  The  preparation  is  now  in  the  Museum 
of  the  College  of  Surgeons. 

In  fracture  of  the  lower  jaw  in  children — a  very  rare 
accident — when  the  fracture  happens  to  involve  the  cavity 
in  which  a  permanent  tooth  is  being  developed,  exfoliation 
of  the  tooth,  with  a  portion  of  the  alveolus,  is  almost  certain 
to  ensue,  as  was  noticed  by  Mr.  Vasey  in  a  case  occurring 
in  St.  George's  Hospital. 

Paralysis  and  Neuralgia  from  injury  to  the  inferior  dental 


12       COMPLICATIONS    OF    FEACTURE    OF    THE    LOWER    JAW. 

nerve  may  be  the  immediate  result  of  the  accident,  or  be 
caused  at  a  later  period  by  some  pressure  arising  from  the 
development  of  callus.  In  by  far  the  greater  number  of 
cases  no  injury  of  the  nerves  occurs,  and  this  may  be 
partly  explained,  as  Boyer  originally  pointed  out,  by  the 
fact  that  "  the  greater  part  of  these  fractures  takes  place 
between  the  symphysis  and  the  foramen  by  which  the  nerve 
comes  out." 

A  case  was  recorded  by  Mr.  W.  G.  Spencer  in  the 
Transactions  of  the  Pathological  Society,  1887,  in  which  a 
woman,  aged  fifty,  met  with  a  fracture  between  the  first  and 
second  molar  teeth  on  the  left  side,  from  direct  violence. 
She  complained  of  much  pain,  which  was  limited  to  the 
area  of  distribution  of  the  inferior  dental  nerve.  There  was 
no  displacement  at  the  seat  of  fracture  when  the  patient 
was  seen,  nor  was  there  any  bleeding  from  the  inferior 
dental  artery.  There  were  no  changes  in  the  skin  of  the 
cheek  beyond  bruising. 

A  case  of  paralysis  of  the  inferior  dental  nerve,  from  a 
gunshot  wound  of  the  ramus,  which  was  under  my  care 
some  years  ago,  will  be  subsequently  referred  to  ;  and 
Malgaigue  describes  a  specimen  in  the  Musee  'Dupuytren, 
also  the  result  of  gunshot  injury,  in  which  the  dental  nerve 
was  ruptured,  and  its  canal  obliterated  at  the  seat  of  fracture 
(see  Fig.  7). 

Temporary  paralysis  of  the  inferior  dental  nerve  must  be 
of  rare  occurrence,  since  Malgaigne  did  not  meet  with  it ; 
and  Hamilton  thinks  that  "  the  explanation  may  be  found 
in  the  fact  that  the  fragments  seldom  overlap  to  any  appre- 
ciable extent,  and  that  even  the  displacement  in  the  direction 
of  the  diameters  of  the  bone  is  generally  inconsiderable,  or, 
if  it  does  exist,  it  is  easily  and  promptly  replaced."  He 
thinks,  moreover,  that  temporary  anaesthesia  of  the  chin 
might  not  improbably  be  overlooked  at  first,  and  would  have 
ceased  by  the  time  the  apparatus  was  removed.  A.  Berard 
saw  a  case  of  vertical  fracture  without  displacement  between 
the  second  and  third  molar  teeth,  in  which  complete  tempo- 
rary anaesthesia  of  the  lip  and  chin  as  far  as  the  median 


INJUEY    TO    BASE    OF    SKULL.  13 

line  existed  (Gazetle  des  ffopitcmx,  August  loth,  1841).  A 
case  of  temporary  paralysis  of  the  dental  nerve,  from  fracture, 
is  mentioned  also  by  Eobert  (Gazette  elcs  Hopitmix,  1859, 
p.  I  5  7),  occurring  in  a  woman,  aged  sixty-four,  wlio  was  run 
over  by  a  carriage,  and  who  also  suffered  from  fracture  and 
displacement  of  the  malar  bone,  with  pcr^iifwicw^  anaesthesia 
of  the  infra-orbital  nerve. 

An  instance  of  neuralgia,  consequent  upon  old  fracture  of 
the  lower  jaw,  occurred  in  St.  Bartholomew's  Hospital  in 
1863.  Mr.  Wormald,  under  whose  care  the  patient  was, 
opened  up  the  dental  canal  and  excised  a  portion  of  the 
inferior  dental  nerve  with  the  most  satisfactory  result. 
{Medical  Times  and  Gazette,  April  4th,  1863.) 

Injury  to  Base  of  Skull  and  Brain. — The  cases  of  convul- 
sions coincident  with  fracture  of  the  jaw,  recorded  by  Eossi 
and  riajani,  would  appear  to  have  been  due  to  injury  of  the 
brain,  the  result  of  the  original  accident  and  unconnected 
with  the  fracture ;  but  it  may  happen  that  direct  injury  may 
be  inflicted  on  the  skull  by  the  broken  jaw.  Thus,  Dr. 
Lefevre  (Journal  Hehdomadaire,  1834)  gives  the  case  of  a 
sailor,  aged  twenty-two,  who  fell  from  a  height  upon  his 
chin,  with  the  following  result.  There  was  almost  com- 
plete inability  to  open  the  mouth,  the  jaws  beiug  tightly 
closed  and  the  lower  drawn  backwards  and  a  little  to  the 
left.  There  were  tenderness  and  ecchymosis  in  the  left 
temporo-maxillary  region,  and  a  little  blood  flowed  from  the 
left  ear.  The  case  was  diagnosed  to  be  one  of  fracture  of 
the  neck  of  the  condyle.  The  man  died  six  months  after 
with  brain  symptoms,  and,  on  opening  the  head,  the  left 
glenoid  cavity  was  found  driven  in,  with  a  starred  fracture 
of  the  temporal  bone,  between  the  fragments  of  which  the 
condyle  of  the  jaw  was  found.  There  was  a  large  abscess 
in  the  brain. 

Similarly,  in  the  Museum  of  St.  George's  Hospital,  there 
is  a  temporal  bone  with  the  unbroken  condyle  of  the  inferior 
maxilla  driven  through  the  glenoid  cavity,  producing  a  frac- 
ture of  the  middle  fossa  of  the  base  of  the  skull,  in  a  case 
where  there  was  an  extensive  comminuted  fracture  of  the 


14       COMPLICATIONS    OF    FRACTURE    OF   THE    LOWER    JAW. 

jaw  itself,  which,  however,  is  not  preserved.  In  contrast 
with  this  may  be  mentioned  another  case  which  also  occurred 
in  St.  George's  Hospital,  where,  the  neck  of  the  condyle  and 
the  base  of  the  coronoid  process  having  been  broken  through, 
the  lower  fragment  was  displaced  and  had  produced  laceration 
of  the  meatus  auditorius  externus,  separating  the  cartilaginous 
from  the  osseous  portion  for  nearly  half  its  circumference. 
In  this  case  considerable  serous  discharge  flowed  from  the 
ear,  leading  to  the  suspicion  of  injury  to  the  skull,  but  there 
were  no  brain  symptoms,  and  the  patient  dying  with  delirium 
tremens,  the  skull,  the  membranes,  and  the  brain  were  found 
perfectly  healthy. 

In  connection  with  these  cases  may  be  mentioned  those 
recorded  by  M.  Morvan  (Archives  Gen&ales,  1856),  who 
gives  two  cases  of  his  own,  and  one  by  Montezzia,  where  a 
blow  on  the  chin  was  followed  by  bleeding  from  the  ear ; 
and  one  case  by  Tessier,  where  a  double  fracture  of  the  jaw 
from  a  kick  by  a  horse  was  followed  by  bleeding  from  both 
ears.      In  all  these  instances  the  patients  recovered. 

Abscess  and  Necrosis. — Inasmuch  as  nearly  all  fractures 
of  the  lower  jaw  are  compound  into  the  mouth,  it  is  evident 
that  the  seat  of  fracture  cannot  be  kept  free  from  septic 
infection,  and,  as  a  consequence,  a  certain  amount  of  sup- 
puration nearly  always  ensues.  In  the  majority  of  cases  the 
suppuration  remains  limited  to  the  injured  part,  the  pus 
escaping  readily  into  the  mouth  through  the  lacerated  gum. 
This  suppuration  may  spread  to  the  alveolar  portion  of  the 
bone,  and  cause  the  necrosis  of  a  small  portion  of  the  alveolus, 
without  producing  any  permanent  deformity.  In  other  cases, 
however,  the  pus  tends  to  accumulate,  forming  abscesses  of 
varying  extent,  which  usually  point  below  the  jaw.  As  a 
consequence  of  this,  portions  of  the  lower  jaw  become 
necrosed.  In  some  cases  the  whole  thickness  of  the  bone 
may  become  necrosed,  especially  when  the  fracture  is  com- 
minuted, leading  to  considerable  deformity.  Of  this  a 
specimen  in  St.  George's  Hospital  Museum  (Fig.  4)  affords 
a  good  example,  a  loss  of  substance  to  the  right  of  the 
symphysis  having  occurred,   leading   to  the  union   of    the 


ABSCESS    AND   NECEOSIS. 


15 


halves  of  the  bone  at  an  acute  angle.  A  still  better 
example  of  the  same  kind  of  deformity,  and  from  a  similar 
cause,  is  seen  in  Fig.  5  taken  from  a  model  lent  to  me  by 

Fig.  4. 


Mr.  Hepburn.  The  patient  several  years  ago  received  a 
kick  from  a  horse,  which  produced  a  compound  comminuted 
fracture  of   the  lower  jaw.       The   central  portion  became 


Fig.  5, 


Fig.  6. 


necrosed  and  was  removed  by  the  late  Mr.  Aston  Key,  and 
appears  to  have  extended  from  the  second  bicuspid  tooth  of 
the  right  side  to  the  hrst  molar  on  the  left,  the  intervening 


16       COMPLICATIONS   OF    FEACTURE    OF    THE    LOWER    JAW. 

teeth  being  wanting.  The  result,  as  seen  in  the  model,  is 
that  the  two  halves  of  the  jaw  are  united  at  an  angle, 
of  which  the  second  bicuspid  tooth  forms  the  apex,  the  jaw 
being  so  much  contracted  that  this  tooth  is  three-quarters 
of  an  inch  behind  the  upper  incisors,  as  can  be  well  seen  in 
Fig.  6.  Here,  by  the  skilful  adaptation  of  artificial  apparatus,, 
Mr.  Hepburn  has  been  enabled  to  restore  the  power  of  masti- 
cation and  articulation,  which  was  previously  much  impaired, 
so  that  the  patient  (a  clergyman)  is  able  to  perform  his  duties 
with  satisfaction. 

A  remarkable,  and  I  imagine  unique,  case  of  necrosis  and 
exfoliation  of  the  two  halves  of  the  symphysis  menti  occurred 
to  Mr.  Henry  Power,  who  has  been  good  enough  to  give  me 
the  details  of  tlje  case.  Here  the  patient  sustained  a  com- 
pound fracture  of  the  symphysis  by  a  severe  fall,  and  some 
months  after,  during  the  whole  of  which  time  profuse  sup- 
puration was  going  on  in  the  part,  two  thin  lamellge  of  bone, 
apparently  the  surfaces  of  the  symphysis,  came  away,  after 
which  rapid  solidification  of  the  fracture  ensued. 

Boyer,  in  his  lectures,  mentions  having  extracted  from  a 
fistula  in  the  meatus  auditorius  externus,  the  necrosed  con- 
dyle of  a  man  who  had  had  a  fracture  of  the  neck  of  the 
bone  seven  or  eight  months  before. 

Salivary  fistula  may  result  from  a  compound  fracture  of 
the  lower  jaw,  or  from  an  abscess  bursting  externally  in  the 
case  of  a  simple  fracture.  The  treatment  would  of  course 
be  that  for  salivary  fistula  arising  from  other  causes.  A  case 
occvirred  under  the  author's  care,  in  which  a  salivary  fistula 
was  connected  with  necrosis  and  false  joint  in  the  ramus  of 
the  jaw,  following  a  gunshot  injury,  and  was  successfully 
closed. 

Dislocation. — I  have  been  able  to  find,  in  the  standard 
authors,  the  records  of  only  two  cases  of  fracture  of  the  body 
of  the  jaw  complicated  by  dislocation  of  the  condyle  from 
the  glenoid  cavity,  and  the  accident  must  of  necessity  be  a 
rare  one,  for  the  fact  of  fracture  having  occurred  would 
tend  to  prevent  the  dislocation,  since  the  leverage  necessary 
would  thus  be  interfered  with.     The  cases  in  question  are 


DISLOCATION    WITH    FRACTURE.  l7 

given  by  Malgaigne  in  his  work  on  "  Dislocations,"  one  being 
recorded  by  Uelamotte,  who  saw  a  fracture  of  the  body  of 
the  jaw  with  double  dislocation  produced  by  the  kick  of  a 
horse,  in  a  girl  of  between  eleven  and  twelve  years.  The 
other  was  a  more  remarkable  case,  recorded  by  Eobert,  who 
saw  a  dislocation  of  the  left  condyle  outwards,  with  fracture 
of  the  jaw  in  front  of  the  right  ramus,  in  a  man  who  was 
knocked  down  on  his  left  cheek,  the  wheel  of  a  carriage 
passing  over  the  right. 

A  third  case,  however,  is  reported  by  Mr.  Croker  King 
{Ditblin  Hospital  Gazette^  1855),  and  occurred  in  a  boy  of 
eight,  who  suffered  a  fracture  at  the  symphysis  with  dislo- 
cation of  the  left  condyle  upwards  and  backwards.  There 
was  bleeding  from  the  ear,  and  the  chin  was  much  retracted 
and  turned  to  the  left ;  the  mouth  was  open,  but  could  be 
closed,  and  it  was  then  observed  that  the  lower  molars  over- 
lapped the  upper,  but  that  the  lower  incisors  were  at  least 
one  inch  'behind  the  upper.  Reduction  was  easily  effected, 
and  the  case  did  well.  (Owing  to  an  obscurity  and  apparent 
contradiction  in  the  report,  this  case  has  been  put  down  by 
Weber  as  an  instance  of  unusual  dislocation  without  fracture.) 

A  fourth  case  of  the  kind  is  also  briefly  referred  to  by 
Mr.  Gunning,  of  New  York,  in  his  paper  on  "  Interdental 
Splints'^  (New  York  Ifcdical  Journal,  1866):  "The  patient 
was  thirty-six  years  old ;  the  jaw  was  fractured  through 
the  symphysis  and  the  right  condyle  dislocated  oidioard  and 
hachiuard,  February  loth,  1866,  in  falling  down  stairs  and 
striking  the  chin  on  a  small  desk."  The  dislocation  was 
reduced  before  Mr.  Gunning  was  called  in. 

The  case  of  fracture  of  the  glenoid  cavity  by  the  dis- 
placed condyle  in  St.  George's  Hospital,  already  referred  to, 
cannot  be  regarded  as  one  of  true  dislocation.  The  treat- 
ment in  these  cases  would  of  course  be  reduction  of  the 
dislocation  before  setting  the  fracture. 

In  fractures  of  the  neck  of  the  jaw  the  condyle  itself  has 
been  found  displaced.  Thus  Holmes  Coote  (in  his  article  on 
Injuries  of  the  Face,  Holmes'  "  System  of  Surgery,"  vol.  ii) 
mentions  that  Bonn,  writing  in  1783,  gives  an  account  of 

B 


18       COMPLICATIONS    OF   FKACTUEE    OF    THE    LOWER   JAW. 

a  case  of  the  kind.  There  was  a  longitudinal  fracture  in  the 
middle  of  the  bone,  and  at  the  same  time  the  right  condyle 
was  broken  off  and  dislocated  forwards  and  inwards,  lying 
united  by  callus  near  the  foramen  ovale.  The  pointed  upper 
extremity  of  the  neck  of  the  lower  jaw  articulated  with  the 
glenoid  cavity,  and  the  separated  head  with  the  lateral  part 
of  the  tubercle  of  the  temporal  bone.  There  was  motion  in 
the  false  joint.  The  same  author  mentions  a  case  of  fracture 
and  dislocation  of  both  condyles  of  the  lower  jaw,  in  a 
young  man  who  had  numerous  injuries  and  lived  five  weeks. 
The  condyles  were  found  to  be  broken  off,  and  fixed  near 
the  foramen  ovale  on  either  side. 

Fig.  7.   . 


Irregular  Union. — Where  the  displacement  of  the  frag- 
ments has  been  great,  it  may  be  impossible  to  keep  them 
in  proper  position,  and  the  result  may  be  an  irregular  union 
of  the  bone,  interfering  more  or  less  with  its  functions  in 
after-life.  This  is  particularly  liable  to  occur  in  cases  of 
double  fracture,  where  the  central  x^oi'tion  of  the  jaw  is 
much  displaced  by  the  muscles  attached  to  it ;  and  Mal- 
gaigne  gives  a  drawing  from  a  specimen  of  the  kind  in  the 
Mus^e  Dupuytren  (Fig.  7),  in  which  the  middle  fragment 
is  displaced  downwards  and  backwards,  and  has  also  under- 
gone such  a  change  of  position  that  its  lower  border  is  in- 
clined forward,  and  its  anterior  surface  looks  almost  directly 
upwards,  the  union  on  one  side  being  partly  fibrous. 

An  almost  precisely  similar  state  of  things  existed  in  a 
case  of  double  fracture  which  came  under  Mr.  Bickersteth's 


UNUNITED    rUAGTUrvE.  19 

care,  and  wliicli  will  bo  found  in  detail  under  the  head  of 
"  Treatment  of  Ununited  Fracture,"  the  central  portion  of 
the  jaw  having  become  much  depressed,  and  united  on  one 
side,  so  that  when  the  molars  were  in  contact  the  incisor 
teeth  were  separated  more  than  half  an  inch,  the  opposite 
fracture  being  still  ununited.  Here  Mr.  Bickersteth  reme- 
died the  deformity  by  sawing  through  the  bone  at  the  seat 
of  the  united  fracture,  and  replacing  the  fragment  in  its 
proper  position. 

The  specimen  of  united  fracture  in  University  College 
Museum  illustrates  very  well  the  effect  of  irregular  union 
upon  the  teeth,  and  the  masticatory  power  of  the  jaw.  The 
fraccure  was  in  the  right  molar  region,  and  appears  to  have 
led  to  the  loss  of  all  the  teeth  on  that  side  except  the  last 
molar.  The  irregular  union  has  resulted  in  a  contraction  of 
the  alveolar  arch,  so  that  the  left  teeth  have  been  thrown 
within  those  of  the  upper  jaw,  with  the  result  of  wearing 
away  the  opposed  surfaces  of  the  two  sets — viz.,  the  lower 
teeth  on  their  outer  and  the  upper  on  their  inner  surfaces. 
Hamilton  expresses  an  opinion,  "  that  time  and  the  constant 
use  of  the  lower  jaw  in  mastication  will  gradually  effect  a 
marked  improvement  in  the  ability  to  bring  the  opposing 
teeth  into  contact."  The  specimen  above  referred  to  illus- 
trates the  only  mode  in  which  such  an  improvement  could, 
in  my  opinion,  occur. 

The  deformity  resulting  from  loss  of  a  portion  of  the 
bone  near  the  symphysis,  has  been  already  referred  to  under 
the  head  of  "  Necrosis."  Loss  of  substance  in  other  parts  of 
the  jaw  is  apt  to  result  in  fibrous  union  or  false  joint,  and 
this  is  especially  the  case  in  gunshot  injuries. 

Ununited  Fracture. — Fractures  of  the  lower  jaw  ordinarily 
unite  with  great  rapidity  and  certainty,  notwithstanding  the 
difficulties  often  met  with  in  maintaining  perfect  apposition 
of  the  fragments.  Hamilton  has  noticed  one  instance,  in  an 
adult  person,  in  which  the  bone  was  immovable  at  the  seat 
of  fracture  on  the  seventeenth  day,  and  says  that  in  no 
instance  under  his  own  observation  has  the  bone  refused 
finally  to  unite,  although  union  has  been  delayed  as  long 


20       COMPLICATIONS    OF    FEACTURE    OF    THE    LOWER    JAW. 

as  eleven  weeks.  Cases  of  non-union  and  false  joint  have, 
however,  been  recorded  and  treated  hy  Physick,  Dupuytren, 
and  others  ;  and  a  case  has  already  been  referred  to,  which 
occurred  under  my  own  care,  in  which  false  joint  followed 
a  gunshot  injury  of  the  ramus  of  the  jaw.  The  liability 
of  the  lower  jaw  to  false  joint,  as  compared  with  other 
bones,  may  be  gathered  from  a  table  of  150  cases  drawn 
up  by  Norris  (American  Journal  of  Medical  Sciences, 
January,  1842).  Of  these  150  cases  48  occurred  in  the 
femur,  48  in  the  humerus,  33  in  the  leg,  19  in  the  forearm, 
and  two  in  the  lower  jaw. 

Non-union  may  be  simply  the  result  of  neglect  of  treat- 
ment, and  union  may  take  place  readily  as  soon  as  the  parts 
are  placed  under  favourable  circumstance.  Thus,  a  patient 
was  under  Mr.  Wormald's  care  who,  five  weeks  before  ad- 
mission into  St.  Bartholomew's  Hospital,  had  fractured  his 
jaw  between  the  canine  and  bicuspid  teeth  on  the  left  side, 
for  which  he  had  not  been  treated.  There  was  some  little 
necrosis,  and  sinuses  had  already  formed  beneath  the  chin ; 
but  under  appropriate  treatment  the  bone  thoroughly  united 
in  five  weeks.  {Medical  Times  and  Gazette,  Jan.  17th, 
1863.)  And  yet,  on  the  other  hand,  fracture  of  the  jaw 
has  no  doubt  been  occasionally  untreated,  and  still  has 
united.  Thus,  Boyer  saw  consolidation  occur,  though  not 
without  deformity,  in  a  water-carrier  who  would  not  endure 
any  dressing,  nor  abstain  from  either  speaking  or  chewing 
when  the  pain  did  not  prevent  him.  Notwithstanding  the 
most  careful  treatment,  however,  the  jaw  may  fail  to  unite 
if  the  case  has  been  complicated  in  any  way.  Thus,  the 
late  Mr.  Berkeley  Hill  mentioned  a  case  {British  Medical 
Journal,  March  2nd,  1867)  of  double  fracture,  where  great 
difficulty  was  experienced  in  adapting  suitable  apparatus, 
and  where  one  fracture  united  perfectly,  but  the  other 
remained  ununited.  And  again,  on  the  other  hand,  over- 
solicitous  attention  appears  occasionally  to  interfere  with 
union  ;  for  A.  Berard  relates  the  singular  case  of  a  child 
whose  fracture  made  no  progress  towards  recovery  till  the 
apparatus,    an    ordinary   bandage,   was  removed ;  and  Mr. 


UNUNITED    FKACTUKE.  21 

Hill's  case,  mentioned  above,  illustrates  the  same  point,  for 
lie  informs  me  that  the  second  fracture  became  consolidated 
without  any  treatment. 

The  occurrence  of  necrosis  at  the  point  of  fracture  is  the 
most  probable  cause  of  non-union,  and  a  small  amount  of 
this  may  prevent,  or  at  least  delay,  the  union  taking  place, 
as  in  Mr.  Power's  case,  where  two  thin  lamellae  exfoliated 
from  the  symphysis ;  and,  moreover,  callus  is  not  thrown  out 
so  copiously  for  the  repair  of  fractures  of  the  jaw  as  it  is  in 
the  long  bones.  Gunshot  injuries  seem  especially  liable  to 
produce  ununited  fractures  of  the  lower  jaw,  probably  by 
inducing  necrosis ;  and  of  this  an  example  under  the  author's 
care  has  been  already  alluded  to.  On  this  subject  the  late 
Dr.  "Williamson,  of  Fort  Pitt,  has  made  the  following  obser- 
vations in  his  work  on  "  Military  Surgery,"  p.  22  : — 

"  Ununited  fracture  of  the  lower  jaw  does  not  seem  to 
have  been  of  such  frequent  occurrence  amongst  the  wounded 
from  the  Crimea  as  those  from  India.  Six  were  admitted 
from  India  with  fracture  of  the  lower  jaw.  Of  these  three 
were  invalided,  two  sent  to  duty,  and  one  to  modified  duty. 
Of  these  six  cases,  three  were  instances  where  the  fracture 
remained  still  ununited,  though  the  ends  of  the  bone  were 
in  contact.  In  one  case  the  ball  struck  one  side  of  the 
lower  jaw,  and  was  cut  out  on  the  opposite  side  one  month 
after,  fracturing  the  bone  on  both  sides.  In  one,  the  ball 
was  cut  out  from  below  the  tongue.  In  one  case,  from  a 
shell  wound,  there  was  a  double  fracture,  one  on  the  right 
side  of  the  ramus,  and  also  another  near  the  symphysis,  witli 
great  laceration  of  soft  parts,  and  resulting  deformity  ;  the 
first-named  fracture  remained  ununited.  In  another  case, 
there  was  a  double  fracture  from  a  musket-ball  ;  the  frac- 
ture at  the  entrance  of  the  ball  still  remains  ununited,  that 
at  the  exit  has  become  united.  In  one  case,  from  round 
shot,  the  whole  of  the  left  ramus  of  the  lower  jaw  had  been 
extracted  at  the  time,  or  came  away  by  exfoliation,  leaving 
a  large  chasm  and  great  deformity  on  this  side  of  the  cheek 
from  laceration  of  the  soft  parts.  In  one  case  there  was  a 
fracture  on  the  Jeft  side, at  the  angle  of  the  jaw,still  ununited." 


22       COMPLICATIONS    OF    FRACTURE    OF   THE   LOWER   JAW. 

A  remarkable  case  of  ununited  fracture  in  the  mental 
region,  the  result  of  gunshot  injury  in  the  Crimea,  is 
recorded  by  the  late  Mr.  Cox  Smith,  of  Chatham  {Dental 
Review,  185  8-9),  and  was  satisfactorily  treated  mechanically 
by  that  gentleman.  The  condition  of  the  parts  was  briefly 
as  follows : — The  symphysis  with  the  incisors,  right  canine, 
and  one  bicuspid  tooth,  having  been  carried  away,  the  jaw 
was  divided  into  two  unequal  portions,  which  fell  together 
when  at  rest ;  but  upon  opening  the  mouth  the  left  only 
was  fully  acted  upon  by  the  muscles  and  the  right  rode  over 
it,  as  shown  in  the  illustration.      (Fig.  8.)      Much  pain  was 


Fig.  8. 


Fig.  9. 


caused  by  any  attempt  to  separate  the  two  fragments  so  as  to 
make  them  correspond  to  the  teeth  of  the  upper  jaw ;  hence 
mastication  was  impossible,  articulation  was  much  interfered 
with,  and  the  patient  could  only  sleep  on  his  back,  since 
lying  on  either  side  caused  displacement  of  the  correspond- 
ing section  of  the  jaw.  Fig.  9  shows  the  model  first  taken 
by  Mr.  Smith,  and  its  resemblance  to  cases  of  united  fracture 
with  loss  of  substance  in  the  incisor  region  previously 
described,  will  be  at  once  noticed.  The  treatment  of  this 
interesting  case  will  be  referred  to  under  another  section. 

The  case  of  ununited  fracture  successfully  treated  by 
Dupuytren  was  also  the  result  of  a  gunshot  injury,  and  the 
following  was  the  condition  of  the  parts  when  the  patient 
came  under  tliat  surgeon's  care,  four  years  after  the  receipt 


FALSE    JOINTS,  '!•> 

of  the  injury  (Diipuytreu's  Lecons  Orcdes,  vol.  iv).  The  ball 
had  struck  the  right  side  of  the  jaw  just  in  front  of  the 
masseter,  and  had  carried  away  a  portion  of  the  bone  at  the 
junction  of  the  body  with  the  ramus.  The  posterior  frag- 
ment, which  contained  the  wisdom  tooth,  was  twisted  so 
that  the  tooth  looked  towards  the  tongue,  and  at  the  same 
time  was  drawn  outwards  into  the  cheek.  The  anterior 
fragment  formed  by  the  remainder  of  the  bone  was  displaced, 
so  that  its  fractured  end  was  carried  to  the  right  side  and 
below  the  other,  an  interval  of  an  inch  intervening,  corre- 
sponding to  the  first  and  second  molar  teeth  which  had  been 
carried  away.  The  riding  of  the  fragments  was  so  great 
that  the  second  bicuspid  tooth  was  in  contact  with  the 
wisdom  tooth,  when  the  parts  were  left  to  themselves  ;  but, 
when  traction  was  made,  a  space  of  an  inch  was  produced 
between  them.  Of  course  therefore  the  teeth  of  the  two 
jaws  did  not  correspond,  and  there  was  consequently  great 
difficulty  of  mastication,  which  was  increased  by  the  want 
of  power  in  the  jaw  itself.  If  unsupported  by  a  bandage 
the  jaw  dropped,  the  mouth  remained  open  and  saliva 
dribbled  out,  the  chin  being  carried  over  to  the  right  side. 

False  Joints. — In  some  cases,  where  bony  union  between 
the  fragments  of  a  broken  bone  has  failed  to  take  place,  the 
two  fragments  may  be  united  together  by  fibrous  tissue  in 
two  ways,  forming  what  are  termed  false  joints.  First,  the 
union  may  more  or  less  resemble  a  synarthrosis,  the  fractured 
ends  being  held  together  by  ligamentous  tissue.  Secondly 
the  union  may  closely  resemble  in  arrangement  a  diarthrodiai 
joint.  A  ligamentous  capsule  is  formed,  and  is  lined  by  a 
smooth  membrane  which  secretes  synovia.  The  only  museum 
specimen  of  false  joint  in  the  lower  jaw  I  have  met  with  is 
in  University  College  (Fig.  i  o),  and  belongs  to  the  first  kind, 
since  it  is  a  good  example  of  fibrous  union  filling  the  interval 
between  the  right  canine  tooth  and  the  ramus  of  the  jaw, 
there  having  evidently  been  considerable  loss  of  bony  sub- 
stance at  the  seat  of  fracture.  A  very  similar  specimen  is, 
I  am  informed,  in  the  Museum  of  the  Eoyal  College  of 
Surgeons  in  Edinburgh,  the  fibrous  tissue  extending  from 


24       COMPLICATIONS    OF  FEACTUEE    OF    THE    LOWEE    JAW. 

the  symphysis  to  the  left  "bicuspid  teeth.  I  have  no  doubt, 
however,  that  the  other  form,  the  true  false  joint,  does  occur 
in  the  lower  jaw,  both  as  the  result  of  violence  (and  particu- 
larly in  the  ramus  of  the  jaw),  and  as  the  result  of  operative 
interference,  having  had  the  opportunity  of  watching  the 
formation  of  a  false  joint  in  cases  in  which  I  performed 
Esmarch's  operation  for  closure  of  the  jaws,  which  will  be 
referred  to  in  another  part  of  this  essay. 
The  amount  of  inconvenience  which  the  patient  experiences 

Fig.  io. 


from  an  ununited  fracture  of  the  jaw  will  vary  according  to 
the  position  of  the  false  joint.  In  the  ramus  it  appears  to 
give  very  little,  if  any,  inconvenience,  the  new  joint  perform- 
ing the  function  of  the  temporo-maxillary  articulation ;  and 
the  same  may  be  said,  according  to  my  experience,  of  the 
false  joints  purposely  made  for  the  relief  of  closure  of  the 
jaws,  although  in  the  body  of  the  bone,  since  the  portion  of 
the  jaws  posterior  to  the  joint  is  immovably  fixed  by  the 
cicatrices.  When,  however,  a  false  joint  occurs  in  the  body 
of  an  otherwise  natural  bone,  great  inconvenience  results,  the 
patient  being  unable  to  masticate  properly  ;  and  his  health 
is  apt  to  suffer,  as  was  the  case  with  Dr.  Physick's  patient, 
who  was  successfully  treated  by  the  use  of  a  seton  eighteen 


FALSE    JOINTS.  25 

mouths  after  the  accident.  Here  the  fracture,  origiually 
double,  united  on  the  right  side,  but  the  left,  which  was 
broken  obliquely,  remained  ununited.  {Philaddfliia  Journal 
of  Med.  and  Phys.  Sciences,  vol.  v,  p.  1 1 6.)  A  case  is  related 
also  by  Horeau  {Journal  de  Medccine,  par  Corvisart,  x,p.  1 95)> 
which  shows  the  inconveniences  experienced.  A  colonel 
received  a  gunshot  wound  which  broke  the  right  side  of  the 
body  of  the  jaw  some  lines  from  its  junction  with  the  ramus, 
resulting  in  a  false  joint  between  the  first  and  second  molar 
teeth.  In  the  ordinary  condition  of  things  these  two  teeth 
were  on  the  same  level,  and  they  were  not  deranged  even 
by  pushing  the  fragments  from  behind  forward  or  from 
before  backward.  But  if  the  posterior  fragment  was  raised 
and  the  anterior  depressed,  the  second  molar  tooth  was 
several  lines  above  the  level  of  the  first.  The  result  was 
great  difficulty  in  chewing  on  the  injured  side,  and  con- 
sequently the  food  was  habitually  carried  to  the  left  molar 
teeth,  and  its  trituration  was  neither  easy  nor  complete, 
The  digestion  became  impaired,  and  the  patient  suffered 
from  pain  after  food,  &c.  I  have  recently  seen  a  gentleman 
whom  I  attended  some  years  ago  with  Mr.  Moger,  of  High- 
gate,  and  who  had  received  most  serious  injuries  of  the  face 
from  the  pole  of  a  waggon.  In  this  case  the  patient  barely 
escaped  with  his  life,  owing  to  erysipelas  and  great  constitu- 
tional disturbance.  There  was  double  fracture  with  exten- 
sive necrosis  of  the  lower  jaw,  which  has  resulted  in  a  false 
joint  on  the  right  side  ;  but  for  this  the  patient  has  declined 
all  treatment,  whether  surgical  or  mechanical,  and  though 
he  is  quite  incapacitated  for  mastication,  he  is  well  nourished 
by  means  of  food  passed  through  a  mincing-machine. 


CHAPTER  III. 

TKEATMEXT  OF  FRACTURED  LOWER  JAW. 

The  treatment  of  fractured  lower  jaw  after  the  reduction  of 
-any  displacement,  the  occasional  difficulties  of  which  have 
been  alluded  to  in  a  previous  section,  is  usually  of  a  simple 
■character  ;  but  cases  sometimes  arise  in  which  the  most 
carefully  adapted  mechanical  contrivances  fail  to  effect  a 
good  union.  The  apparatus  employed  for  the  maintenance 
of  the  fractured  portions  in  apposition  may  be  conveniently 
•divided  into  the  following  groups  : — 

1.  Bandages  or  slings. 

2.  Splints,  Avliich  may  be  external  to  the  mouth,  inside 

the  mouth,  or  a  combination  of  the  two. 

3.  Ligature  of  the  teeth. 

4.  Wiring  of  the  bony  fragments. 

It  may  be  advisable  in  some  cases  to  combine  two  or  more 
of  these  methods. 

I.  Bandcujcs  or  Slings. — The  simplest  form  of  external 
apparatus  consists  of  the  ordinary  four-tailed  bandage  or 
sling,  with  a  slit  for  the  chin  to  rest  in  (Fig.  11).  This  is 
made  of  a  piece  of  bandage  about  a  yard  long  and  three 
inches  wide,  which  should  have  a  slit  four  inches  long  cut 
in  the  centre  of  it,  parallel  to  and  an  inch  from  the  edge. 
The  ends  of  the  bandage  should  then  be  split  to  within 
a  couple  of  inches  of  the  slit,  thus  forming  a  four-tailed 
bandage  with  a  hole  in  the  middle.  The  central  sht  can  be 
readily  adapted  to  the  chin,  the  narrow  portion  going  in 
front  of  the  lower  lip,  and  the  broader  beneath  the  jaw ; 
and  the  two  tails  corresponding  to  the  lower  part  of  the 
bandage  are  then  to  be  carried  over  the  top  of  the  head, 


BANDAGES. 


27 


while  the  others  are  crossed  over  them  and  tied  round  the 
nape  of  the  neck.  The  ends  of  the  two  bandages  may  then 
be  knotted  together,  as  seen  in  the  ilhistration. 

A  single  roller  may  be  employed  to  support  the  jaw,  as 
recommended  by  the  American  surgeons  Gibson  and  Barton  ; 
but  this  is  more  difficult  of  application,  and  is  more  apt  to 
become  disarranged. 

Hamilton  states  that  he  has  frequently  noticed  the  ten- 
dency of  the  sling,  as  ordinarily  constructed,  to  carry  the 
Fig.  II.  Fig.  12. 


anterior  fragment  backwards,  especially  when  there  is  a 
■double  fracture.  He  has  devised  a  special  form  of  appa- 
ratus (Fig.  12),  for  which  he  claims  the  following  : — "The 
advantage  of  this  dressing  over  any  which  I  have  yet  seen, 
consists  in  its  capability  to  life  the  anterior  fragment  ver- 
tically ;  and,  at  the  same  time,  it  is  in  no  danger  of  falling 
forwards  and  downwards  upon  the  forehead.  If,  as  in  the 
case  of  most  other  dressings,  the  occipital  stay  had  its 
attachment  to  the  chin,  its  effect  would  be  to  draw  the 
central  fragment  backwards.  By  using  a  firm  piece  of 
leather  as  a  maxillary  band,  and  attaching  the  occipital 
stay  above  the  ears,  this  difficulty  is  completely  obviated." 


28       TEEATMENT  OF  FRACTURED  LOWER  JAW. 

2.  SiMnts. — An  enormous  variety  of  splints  has  been 
designed  to  treat  fractures  of  the  lower  jaw.  It  would  be 
impossible  to  give  anything  like  a  complete  account  of  them 
in  this  work,  and  therefore  only  a  few  methods  illustrating 
the  various  principles  will  be  described. 

(ft)  External. — This  splint  is  very  frequently  used  in 
combination  with  the  four-tailed  bandage.  It  is  made  of 
paste-board,  gutta-percha,  or  some  similar  material.  This 
being  cut  long  enough  to  pass  well  up  to  the  sides  of  the  jaw, 
is  to  be  divided  at  the  ends  so  as  to  resemble  the  four-tailed 
bandage  (Fig.  1 3).  Being  then  softened  in  warm  water  it  can 
be  lined  with  lint  or  some  soft  material  and  adapted  to  the 
jaw,  the  chin  resting  on  its  centre,  and  the  sides  being 
doubled  around  and  beneath  the  bone,  as  in  Fig.  14. 

Fic4. 13.  Fig.  14. 


(h)  Internal. — One  of  the  most  convenient  and  useful  of 
these  is  the  wire  splint,  devised  by  Mr.  Hammond,  L.D.S., 
who  has  kindly  supplied  the  following  details  of  the  method 
of  applying  it. 

To  maize  the  Hammond  Wire-splint. — After  bringing  the 
broken  parts  into  apposition,  tie  them  temporarily  together 
with  silk  passed  outside  the  second  tooth  on  each  side  of  the 
line  of  fracture. 

With  a  suitable  "  tray "  and  very  soft  wax,  take  an 
impression  of  the  mouth  (which  need  not  be  deeper  than 
the  teeth),  supporting  the  chin  while  doing  so  with  the 
left  hand. 

Make  a  model  of  this  in  plaster  of  Paris  in  the  usual 
way.  If  there  has  been  any  displacement  of  the  parts,  saw 
down  between  the  teeth  corresponding  to  the  fracture,  ad- 
just the  several  pieces  to  the  proper  "  bite,"  and  fix  in 
position. 


HAMMOND  S    WIRE    SPLINT. 


29 


Now  take  a  length  of  ii.'on  wire  (stout  hair-pin  size)  and 
carefully  make  a  frame  to  fit  round  the  teeth,  soldering  the 
ends  together  with  silver  solder.  Cut  several  five-inch 
lengths  of  fine  soft  iron  binding  wire — both  ends  of  which 
should  be  cut  to  points,  which  will  greatly  facilitate  the 
passing  of  them  through  the  tartar  between  the  teeth. 
Should  there  be  much  tartar  a  fine  "  broach "  may  be 
necessary. 

Fig.  15. 


To  ap'ply  the  Splint. — Place  the  patient  upright  in  a 
high-back  chair,  and  rinse  the  mouth.  Slip  the  frame  over 
the  teeth,  holding  it  gently  in  place  with  the  left  hand,  and 
with  the  right  hand  take  one  of  the  pointed  wires  and  pass 
it  between  the  first  and  second  molars  on  the  left  side, 
directing  it  slightly  downwards  so  that  the  end  will  come 
out  under  the  inner  bar  of  the  frame.  Have  the  forefinger 
of  the  left  hand  inside  to  feel  for  the  point,  and  with  it  turn 
the  wire  upwards  and  outwards  so  as  to  avoid  wounding  the 
tongue.  Then  bring  this  wire  back,  as  shown  in  Fig.  16, 
i.e.,  over  the  inner  bar  of  the  frame,  and   under  the  outer ; 


30 


TEEATMENT    OF    FEACTUEED    LOWEE    JAW 


cross  the  ends  and  turn  them  aside — repeat  this  on  the 
right  side  of  the  mouth.  When  all  the  ligatures  are  passed, 
seize  the  ends  of  the  first  wire  with  a  small  pair  of  phers, 
and  twist  them  on  each  other  nearly  tight,  doing  the  same 
on  the  left  side,  and  when  the  pressure  is  equalized  cut  off 
the  wires  about  half  an  inch  from  the  frame,  as  at  B.  Now 
twist  all  the  ligatures  quite  tight,  and  tuck  them  away  under 
the  frame,  as  at  0.      The   jaw  will  now  he  found  perfectly 

Fig.  1 6. 


firm,  and  the  patient  able   to   bite  steadily  on  it  without 
pain. 

It  will  be  found  after  a  few  dfiys  that  the  ligatures  will 
require  twisting  a  little  tighter  (owing  to  the  movement  of 
the  teeth  in  their  sockets)  ;  this  can  easily  be  done  if  care 
be  taken  to  follow  the  directions  given,  and  never  on  any 
account  to  put  one  wire  round  more  than  one  tooth.  The 
attempted  employment  of  one  long  wire  for  all  the  teeth  by 
some  operators  has  very  injuriously  affected  the  reputation 
of  this  splint  for  firmness  and  solidity,  by  virtue  of  which 
qualities  good  results  can  always  be  obtained. 


HAMMONDS    AVI  RE    SPLINT. 


31 


Dissimilar  metals  must  not  be  used  in  the  construction  of 
the  frame   and  wires,  owing  to  the  galvanic    action  set  up 

Fig.  17. 


and  unpleasant  taste  produced,  not  to  mention  the  irritation 
to  the  teeth. 

A  very  successful  case  treated  in  this  way  was  published' 


Fig.  18. 


/      *\ 


by  Newland-Pedley  {B.  J.  Dent.  Sci.,  1889),  and  Fig.  17 
shows  the  deformity  of  the  lower  jaw  caused  by  the 
fractures,  one  on  each  side  of  the  incisors  and  a  third  run- 
ning    longitudinally    beneath    them.     Fig.    18    shows    the 


32     '   TEEATMENT  OF  FEACTUEED  LOWEE  JAW. 

fractures  adjusted,  and  the  deformity  corrected,  by  sawing 
through,  the  lines  of  fracture  in  the  model  and  re- articulating 
with  a  model  of  the  upper  jaw,  Hammond's  splint  being 
then  applied. 

The  simplest  form  of  apparatus  within  the  mouth  consists 
of  wedges  of  cork,  about  an  inch  and  a  half  long  and  a 
quarter  of  an  inch  in  thickness  at  the  base,  but  sloping 
away  to  a  point,  as  recommended  by  Boyer  and.  Miller. 
These  may  be  placed  between  the  molar  teeth,  and,  if  they 
can  be  kept  in  position,  will  maintain  the  regularity  of  the 
teeth  and  keep  the  incisors  separated  for  the  introduction  of 
food,  a  four-tailed  bandage  bein^  applied  externally.  My 
own  experience  is  that  the  corks  cannot  be  maintained  in 
position,  and  after  a  few  hours  roll  about  in  the  mouth  ; 
and  this  I  find  also  to  have  been  the  experience  of  other 
surgeons,  including  Sir  William  Fergusson,  with  whom  also 
I  fully  agree,  that  the  majority  of  cases  do  well  with  merely 
the  simple  bandage,  not  very  tightly  applied. 

Wedges  of  gutta-percha,  introduced  warm  into  the  mouth, 
so  as  to  become  moulded  to  the  teeth  and  gums,  are  highly 
recommended  by  Hamilton,  both  as  supports  and,  in  some 
degree,  as  lateral  splints  for  the  fracture.  Miitter's  clamp, 
consisting  merely  of  a  plate  of  silver,  folded  over  the  tops 
and  sides  of  two  or  more  teeth  adjacent  to  the  fracture,  is  a 
contrivance  which,  in  its  original  form,  can  have  been  but  of 
little  service,  but  as  modified  by  Mr.  Tomes  and  others  is  a 
very  efficient  method  of  treating  fractures  of  the  body  of  the 
jaw.  The  modification  consists  in  making  the  silver  cap 
fit  accurately  to  the  teeth,  for  some  distance  on  each  side 
of  the  fracture,  by  moulding  it  to  a  plaster  cast  of  the  jaw. 
The  cap  is  then  liaed  with  gutta-percha,  which,  being  warmed 
when  the  apparatus  is  applied,  fills  up  interstices  and  fixes 
the  cap,  the  fragments  being  maintained  in  position  whilst 
the  application  is  being  made.  Although  the  assistance  of 
a  dentist  would  be  required  for  the  proper  preparation  of 
the  cap,  it  may  not  be  out  of  place  to  notice  the  best  method 
of  obtaining  a  satisfactoiy  model  upon  which  the  cap  is  to 
be  formed,  for  which  I  am  indebted  to  Mr.  Tomes.     When 


ciunnixg's  interdental  splint.  83 

the  displacemoiit  of  the  fragments  is  great  (as  is  invariably 
tlie  case  where  such  apparatus  is  required),  it  is  best  to  take 
a  cast  of  the  jaw  in  wax,  without  attempting  to  bring  the 
fragments  into  proper  relation.  Into  this  the  plaster  is 
poured,  and,  when  set,  a  fac-simile  of  the  displaced  fracture 
is  of  course  produced.  By  now  sawing  out  the  piece  of 
plaster  between  the  extremities  of  the  fragments,  these  can 
be  brought  together,  and  a  model  of  the  perfect  jaw  will  be 
produced,  upon  which  the  metal  can  be  carefully  fitted.  "When 
all  is  prepared,  by  carefully  adjusting  the  fracture,  the  cap 
will  of  necessity  fit  and  will  maintain  the  fracture  in  its 
normal  position. 

Mr.  Barrett,  dental-surgeon  to  the  London  Hospital,  has 

Fig.  19. 


kindly  shown  me  models  of  cases  in  which  he  has  obtained 
most  satisfactory  results,  by  both  metal  and  vulcanite  inter- 
dental splints,  secured  in  the  mouth  by  small  screws  passing 
between  the  necks  of  the  teeth.  One  of  his  cases  was  in  a 
child,  and  here  the  delicate  temporary  teeth  suffered  no 
damage  from  the  screws. 

Mr.  Gunning,  of  New  York  {New  York  Medical  Jounud, 
and  British  Journal  of  Dental  Science,  1866),  has  contrived 
a  form  of  interdental  splint,  composed  of  the  vulcanite -rubber 
now  in  common  use  among  dentists,  which  has  yielded  very 
satisfactory  results  in  his  hands,  and  of  which  the  following 
is  a  condensed  description. 

Fig.  19  represents  the  inner  surface  of  a  splint  which 
incloses  all  the  teeth  and  part  of  the  gum  of  the  lower  jaw, 
and  merely  rests  against  the  upper  teeth  when  the  jaws  are 

c 


;4 


TEEATMEXT  OF  FRACTUEED  LOWER  JAW. 


closed.  This  splint  is  adapted  to  the  treatment  of  all  cases 
which  have  teeth  on  both  sides  of  the  fracture,  except  those 
with  obstinate  vertical  displacement.  The  holes  marked  A 
go  through  the  top  of  the  splint,  for  the  purpose  of  syringing 
the  parts  within  with  warm  water  during  treatment.  The 
dark  round  spots  in  all  the  cuts  represent  holes  for  similar 
purposes. 

Mr.  Gunning  has  generally  used  this  splint  without  any 
fastenings,  but  in  children,  or  even  adults,  it  is  sometimes 
advisable  to  secure  it  by  packthread  wire  screws  passing  into 
or  between  the  teeth,  or  by  the  wings  and  band  of  Fig.  21. 

Fig.  20. 


In  cases  with  obstinate  vertical  displacement,  the  splint, 
in  addition  to  fitting  the  teeth  and  gum  of  the  lower  jaw, 
must  also  enclose  the  upper  teeth,  as  shown  in  Fig.  20,  where 
screws  may  be  seen  opposite  both  the  lower  and  upper 
teeth. 

By  this  arrangement  the  fragments  of  the  lower  jaw  are 
secured,  not  only  relatively  to  each  other,  but  also  to  the 
upper  jaw.  B\^  a  triangular  opening,  of  which  one  side  cor- 
responds to  the  cutting  edge  of  the  lateral  incisor,  which 
stood  in  the  end  of  the  fragment  most  displaced  before 
the  splint  was  applied.  C,  an  opening  for  food,  speech,  &c. 
D,  a  channel  for  the  saliva  from  the  parotid  gland  to 
enter  the  mouth,  its  fellow  being  seen  on  the  other  side  of 
the  splint.  E,  a  screw  opposite  the  lower  canine  tooth,  the 
end  of  the  fellow  screw  being  just  discernible.     F,  the  head 


DE.   ANGLE  S    METHOD, 


OO 


of  a  screw  opposite  the  upper  first  molar  tooth,  the  end  of 
its  fellow  being  seen  on  the  other  side. 

This  method  can  be  used  in  cases  where  tliere  are  no 


Fig.  21. 


teeth,  but  has  to  be  modified.  Attached  to  the  splint  are 
metal  wings,  coming  out  of  the  mouth  by  means  of  which 
the  splint  can  be  firmly  fixed  to  the  head  (Fig.  21).  In 
such  cases,  however,  it  is  probably  better  not  to  employ  an 
interdental  splint. 

Fig.  22. 


Fig.  2: 


An  ingenious  method  has  been  devised  by  Dr.  Angle,  of 
Minneapolis,  but  it  could  be  employed  only  by  those 
thoroughly  practised  in  mechanical  dentistry.  He  divides 
cases  of  fracture  into  two  chief  classes. 

''  The  first  class  comprises  all  cases  of  simple  fracture  in 
which  the  teeth  are  good,   especially  on  each  side  of  the 


IdQ 


TKEATMENT  OF  FEACTURED  LOWER  JAW. 


region  of  tlie  fracture.  They  should  be  sufficiently  sound 
and  firm  in  their  attachments  to  afford  good  anchorage  for 
the  appKance  which  supports  the  fracture. 

"  The  second  class  comprises  all  fractures  where  the  teeth 
are  unsuited,  from  any  cause,  for  anchorage,  but  sufficient 
to  give  a  correct  articulation  of  the  jaws  when  they  are  in 
proper  apposition." 

Cases  of  the  first  kind  are  treated  by  carefully  fixing  a 
silver  band  around  a  tooth  on  each  side  of  the  fracture,  and 

Fig.  24. 


then  soldering  a  small  metal  pipe  to  those  bands  as  seen  in 
Fig.  22. 

Cases  of  the  second  kind  are  treated  by  keeping  the  lower 
jaw  firmly  in  contact  with  the  upper  jaw.  This  is  done  by 
surrounding  certain  of  the  teeth  with  metal  bands,  and  con- 
necting thom  by  fine  binding  wire.  Fig.  23  shows  the 
fracture  bands,  and  Fig.  24  the  method  of  fixing  the  lower 
jaw. 

"  It  might  be  urged,  as  an  argument  against  this  method, 
that  the  teeth  being  closed,  and  the  jaws  being  firmly  bound 
together,  the  patient  would  be  unable  to  take  sufficient 
nourishment.  This,  however,  is  untrue ;  for  it  rarely 
happens  that  a  patient  is  found  without  some  teeth  missing, 


Ml;.     IIAVW'AUD.S    METHOD.  :*)7 

thereby  leaving  aLundance  of  space  for  the  passage  of  the 
liquid  foods  ;  and,  even  if  all  the  teeth  were  sound  and  in  per- 
fect position,  it  has  been  proven  there  is  plenty  of  space 
between  the  teeth,  and  behind  the  molars,  and  between  the 
upper  and  lower  incisors,  for  taking  all  nourishment  neces- 
sary. Of  course,  in  such  rare  cases,  much  more  time  would 
be  necessary  in  taking  nourishment."  For  further  parti- 
culars of  Dr.  Angle's  method  the  reader  is  referred  to  his 
paper  in  the  jYcir  Yorh  Medical  Becorcl,  May  31,  1890. 

(c)  Combination  of  External  and  Internal  Splints. — The 
great  difficulty,  in  using  any  form  of  rigid  splints  to  the  jaw, 
is  the  tendency  of  the  support  for  the  chin  to  produce 
abscess  and  ulceration  by  pressing  upon  the  sharp  border  of 
the  bone  ;  and  the  cases  in  which  a  simple  interdental  splint 
would  not  effect  a  cure  must  be  rare. 


Fig.  25. 


Mr.  Howard  Hayward  has  been  very  successful  in  treat- 
ing cases  of  fracture  of  the  jaw,  of  both  recent  and  old  date, 
by  silver  caps,  fitted  accurately  to  the  teeth  on  each  side  of 
the  fracture,  and  also  over  the  gum  to  the  depth  of  half  an 
inch  in  front  and  a  quarter  of  an  inch  behind  them  (Fig. 
25).  To  the  upper  surface  of  the  plate  two  pieces  of  stout 
curved  wire  are  soldered,  so  as  to  turn  round  the  angles  of 
the  mouth  without  touching  them,  and  these  are  attached  to 
a  simple  gutta-percha  splint,  moulded  externally  to  the  jaw, 
and  retained  in  position  by  an  ordinary  four-tailed  bandage. 
Holes  drilled  in  the  metal  cap,  opposite  the  point  of  fracture, 
permit  of  the  exit  of  any  discharge,  but  this  is  usually  insig- 
nificant in  quantity  when  the  fracture  is  once  properly  set. 
Mr.  Hayward  prefers  metal  to  vulcanite  or  gutta-percha  for, 
the  cap,  on  account  of  its  small  bulk,  and  the  consequent 
small  interference  with  the  natural  closure  of  the  mouth — a 


38  TREATMENT    OF    FRACTURED    LOWER  JAW. 

point  of  some  importance,  on  account  of  the  retention  of  the 
saliva. 

Mr.  J.  B.  Bean,  of  Atlanta,  Greorgia,  appears  to  have  em- 
ployed a  vulcanite  interdental  splint  very  similar  to  Mr. 
Gunning's,  but  with  the  addition  of  a  mental  compress,  with 
great  success  among  the  wounded  soldiers  of  the  Confederate 
army,  and  his  apparatus  is  very  favourably  reported  upon 
by  Inspector-General  Covey  (Biclimond  Medical  Journal, 
and  British  Journal  of  Dental  Science,  1866).  Hamilton 
also  speaks  well  of  the  apparatus  in  the  fourth  edition  of  his 
work  on  "  Fractures,"  and  gives  an  illustration. 

A  combination  of  external  and  internal  splints  was  in- 
vented by  Eutenick,  a  German  surgeon,  in  1799,  ^'^^ 
improved  by  Kluge.  It  is  thus  described  by  Dr.  Chester 
{Meclico-Ghirurgical  Eevieiu,  vol.  xx,  p.  471):  "It  consists, 
I  st,  of  small  silver  grooves,  varying  in  size  according  as  they 
are  to  be  placed  on  the  incisors  or  molars,  and  long  enough  to 
extend  over  the  crowns  of  four  teeth  ;  2nd,  of  a  small  piece 
of  board,  adapted  to  the  lower  surface  of  the  jaw,  and  in 
shape  resembling  a  horse-shoe,  having  at  each  horn  two 
holes,  one  on  either  side  ;  3rd,  of  steel  hooks  of  various 
sizes ;  each  having  at  one  extremity  an  arch  for  the  recep- 
tion of  the  lower  lip,  and  another,  smaller,  for  securing  it 
over  the  silver  channels  on  the  teeth,  and  at  the  other  end  a 
screw  to  pa;s  through  the  horse-shoe  splint,  and  to  be  secured 
to  it  by  a  niLt  and  a  horizontal  branch  at  its  lower  surface ; 
4th,  of  a  cap  or  silk  nightcap  to  remain  on  the  head ;  and 
5  th,  of  a  compress  corresponding  in  shape  and  size  with  the 
splint.  The  net  or  cap  having  been  placed  on  the  head  and 
the  two  straps  fastened  to  it  on  each  side,  one  immediately 
in  front  of  the  ear  and  the  other  about  three  inches  farther 
back,  which  are  to  retain  the  splint  in  its  position  by  pass- 
ing through  the  two  holes  in  each  horn ;  a  silver  channel  is 
placed  on  the  four  teeth  nearest  to  the  fracture,  on  this  the 
small  arch  of  the  hook  is  placed,  and  the  screw  end  having 
been  passed  through  a  hole  in  the  splint,  is  screwed  firmly 
to  it  by  a  nut,  after  a  compress  has  been  placed  between  the 
splint  and  the  integuments  below  the  jaw.     If  there  is  a 


LONSDALE'S    APPAKATUS. 


39 


■double  fracture,  two  channels  and  two  liooks  must  of  course 
be  used." 

Bush  invented  a  similar  apparatus  in  1822,  and  Houzelot 
in  1826;  since  which  the  apparatus  has  been  variously 
modified  by  Jousset,  Lonsdale,  Malgaigne,  and  perhaps 
others. 

Lonsdale's  apparatus,  as  the  late  Mr.  Berkeley  Hill  ve- 
laiirked  (British  Medical  Journal,  March  2,  1867),  "is  only 
.suited  to  cases  of  fracture  between  the  incisors,  as  its  ivory 
€ap  is  too  short  to  reach  far  along  the  arch  of  the  teeth.     It 

Fig.  26. 


is  also  very  cumbrous ;  and  causes  great  pain  by  the  pres- 
sure under  the  chin  necessary  to  keep  the  fragment  in  place, 
and  by  the  jogging  of  the  vertical  part  against  the  sternum. " 

Fig.  26  shows  this  apparatus  somewhat  modified  by  Mr. 
Hill.  In  the  ordinary  Lonsdale's  apparatus,  the  rod  carrying 
the  ivory  cap  (a)  for  the  incisors  slides  freely  up  and  down  a 
bar  projecting  downwards  from  the  chin-piece  (b),  and,  when 
in  the  required  position,  is  fixed  by  a  pin.  Mr.  Hill  had  a 
screw  thread  cut  on  the  bar,  on  which  a  nut  (e)  travels  so 
as  to  force  down  the  rod  carrying  the  cap  (a),  and  thereby 
approximate  the  cap  on  the  incisors  to  the  chin-piece. 

When  this  apparatus  is  to  be  applied,  the  fragments  are 
placed  in  position  by  the  hands,  the  ivory  cap  set  on  the 
incisors,  and  the  chin-piece,  which  should  be  well  padded 


40  TREATMENT    OF    FEACTURED    LOWER    JAW. 

with  lint  or  wool  stitched  in  wash-leather,  brought  up  into 
place  under  the  jaw,  and  the  two  made  fast.  The  two 
cheek-pieces  are  then  adjusted  so  as  to  press  lightly  on  the 
jaw  at  each  side,  to  prevent  the  apparatus  from  swaying 
aside  out  of  place ;  and  a  tape  is  fastened  to  a  hole  at 
each  end  of  the  horse- shoe,  and  carried  behind  the  neck, 
to  keep  the  instrument  from  slipping  forwards.  So  applied, 
Lonsdale's  apparatus  permits  opening  of  the  mouth  for 
eating  and  speaking  ;  and,  if  the  fracture  be  single  and 
between  the  incisors,  it  keeps  the  fragments  in  position  very 
fairly. 

3.  Ligature  of  the  Teeth. — Ligature  of  the  teeth,  with 
silk  or  wire,  is  a  method  which  has  frequently  been  employed 
for  the  treatment  of  fractured  jaw,  but  is  unsatisfactory, 
from  the  loosening  of  the  teeth  and  irritation  of  the  gums 
which  are  apt  to  be  produced.  When  employed,  care 
should  be  taken  to  select,  if  possible,  perfectly  sound  teeth 
around  which  to  apply  the  ligature,  which  should  be  pre- 
vented from  sinking  down  to  the  neck  of  the  tooth  so  as  to 
cut  the  gum.  An  astringent  and  antiseptic  wash  should  be 
frequently  employed  during  the  treatment,  to  maintain  the 
healthy  firmness  of  the  gums  themselves  and  to  prevent 
decomposition. 

4.  Wiring  of  the  Bony  Fragments. —  Suture  of  the  jaw 
itself  has  been  employed  from  time  to  time  for  the  treat- 
ment of  both  recent  and  old  fracture,  and  to  insure  the 
union  of  the  two  halves  of  the  bone  after  its  division  for 
removal  of  the  tongue  by  Syme's  method.  Dr.  Kinloch  of 
Charleston  treated,  in  1858,  a  case  of  compound  oblique 
fracture  of  unusual  form,  which  has  been  already  referred 
to  (p.  5),  by  this  method,  after  other  means  had  failed.  "A 
semi-lunar  incision,  about  two  inches  long,  was  made  upon 
the  side  of  the  face,  the  middle  of  the  incision  reaching 
under  the  base  of  the  jaw.  With  Brainard's  smallest-sized 
drill  a  perforation  was  made  through  each  fragment,  the 
drill  being  entered  on  the  outside,  close  to  the  base  of  the 
bone,  and  about  one-eighth  of  an  inch  from  the  rough 
extremity  of  each  fragment,  and  made  to  traverse  the  bony 


AVIRINfr    OF    ITvAGMENTS. 


41 


tissue  and  the  mucous  membrane  covering  it  within  the 
buccal  cavity.  The  drill  was  afterwards  thrust  between  the 
fragments  and  turned  about,  so  as   to   lightly  lacerate   the 

Fig.  27. 


intermediate  connecting  tissue.  A  stout  silver  wire  was 
then  passed  through  the  perforations  in  the  bone,  from 
without  inwards  through  the  posterior  fragment,  and  in  the 


contrary  direction  through  the  anterior  one  ;  and  their  ends 
were  tightly  twisted  together,  so  as  to  bring  the  fragments 
into  secure  apposition. 

"By  the  26th  of  September  good  consolidation  was  effected 


42  TKEAT.MEXT    OF    FEACTUEED    LOWER    JAW. 

and  tlie  suture,  whicli  had  occasioned  but  little  suppuration, 
was  untwisted  and  removed.  On  the  15  th  of  October  the 
patient  left  the  hospital,  with  the  fistulous  opening  healed 
and  a  good  use  of  the  jaw." — American  Journal  of  Mediccd 
Sciences,  July  1859. 

Mr.  Hugh  Thomas  of  Liverpool  has  strongly  advocated 
.  the  use  of  the  wire-suture  in  the  treatment  of  recent 
fractures,  and  two  of  his  illustrative  cases,  which  had  most 
satisfactory  results,  will  be  found  in  The  Lancet,  Jan.  19th, 
1867.  This  method  has  been  more  fully  elucidated  in 
a  pamphlet,  and  consists  either  in  drilling  the  fragments 
and  passing  a  copper  wire,  each  end  of  which  is  then  coiled 
upon  a  "  key "  formed  by  a  steel  rod  with  a  slit  in  it 
(Kg.  27)  ;  or,  in  cases  where  the  teeth  are  sound,  in  passing 
a  loop  of  wire  around  the  teeth  on  each  side  of  the  fracture, 
and  then  twisting  it  up  with  the  key  (Fig.  28).  The 
advantage  of  this  method  is  that  the  wire  can  be  tightened 
from  time  to  time,  as  may  be  required  during  the  treatment, 
without  liability  to  breakage.  I  have  employed  it  in  a  case 
of  division  of  the  jaw  for  removal  of  the  tongue,  with 
advantage  ;  and  my  friend  Mr.  Eushton  Parker  of  Liverpool 
speaks  highly  of  the  method  as  "  the  most  simple  and 
effectual  yet  devised." 


CHAPTER    IV. 

FRACTUKE    OF    THE    UPPER    JAW. 

Fractures  of  the  upper  jaw  are  not  nearly  so  common  as 
those  of  the  lower,  though  their  results  are  often  more 
serious,  owing  to  the  great  violence  necessarily  undergone. 
As  in  the  lower  jaw,  fractures  of  the  alveolus  may  result 
from  the  extraction  of  teeth,  and  particularly  from  the  use 
of  the  "  key ;"  and  so  well  ascertained  was  this  fact,  that 
in  former  days  even,  when  the  key  was  recommended  and 
employed  extensively,  Mr.  Thomas  Bell  ("  On  the  Teeth," 
p.  301)  proscribed  its  use  in  extracting  the  upper  wisdom 
teeth,  on  account  of  the  danger  of  producing  fracture  of  the 
tuberosity  of  the  maxilla,  against  which  the  fulcrum  would 
rest.  A  fracture  thus  produced  may  extend  to  the  palatine 
process,  and  even  to  the  palate  bone,  and  might,  if  extensive, 
give  rise  to  necrosis  and  subsequent  exfoliation  of  large 
portions  of  bone. 

Fractures  of  the  upper  jaw  may  be  produced  indirectly 
by  falls  on  the  face  ;  thus  Liston  ("  Practical  Surgery,"  p.  55) 
narrates  the  case  of  a  man  who,  slipping  on  a  slide  in  the 
street,  fell  and  struck  the  malar  bone  of  the  left  side  ;  he 
had  sustained  a  vertical  fracture  through  the  orbital  process 
of  the  superior  maxilla. 

Direct  blows  upon  the  bone  itself  are,  however,  the  most 
frequent  causes  of  fracture,  and  these,  from  the  nature  of 
the  injury,  are  often  compound. 

Mr,  James  Salter  has  recorded  a  case  (Lancet,  June  i6th, 
i860)  of  a  young  gentleman  who  sustained  a  fracture  of  the 
upper  jaw  from  violent  contact  with  a  fellow- cricketer's 
forehead.     Here  fortunately  none  of  the  incisor  teeth  were 


44 


FRACTURE    OF   THE    UPPER    JAW. 


knocked  out,  as  so  frequently  happens  in  accidents  of  the 
kind ;  but  a  fracture  of  the  bone  was  produced  immediately 
behind  the  right  canine  tooth,  which  extended  backwards  so 
as  to  include  the  alveoli  of  the  bicuspids  and  first  molar 
teeth,  which  were  driven  inwards  towards  the  median  line 
to  the  extent  of  about  one-third  of  an  inch,  as  seen  in  the 
drawing  (Fig.  29).  There  was  a  corresponding  depression 
on  the  outer  side  of  the  jaw,  and  this  was  somewhat  apparent 
also  on  the  face.  Very  little  swelling  followed  the  injury, 
and  there  was  not  much  pain  except  on  manipulation.      The 

Fig.  29. 


Drawing  from  the  plaster  cast  of  the  upper  jaw,  inverted. 

principal  inconvenience  was  due  to  the  want  of  proper 
apposition  of  the  teeth  of  the  two  jaws,  and  the  mouth  con- 
sequently could  not  be  closed  satisfactorily.  On  endeavour- 
ing to  force  the  displaced  bone  into  its  proper  situation, 
considerable  pain  was  produced ;  it  could  not  be  completely 
reduced,  and  resumed  its  former  position  as  soon  as  pressure 
was  withdrawn.  Distinct  crepitus  was  felt  during  this 
manipulation. 

Mr.  Salter  succeeded  in  overcoming  the  tendency  of  the 
fragments  to  displacement  by  the  adaptation  of  a  gold  plate 
(Fig.  30)  to  it  and  to  the  adjacent  teeth,  and  a  complete 
cure  was  the  result. 

The  kick  of  a  horse  often  inflicts  most  serious  injuries 
upon  the  upper  jaw,  and  of  this  the  classical  case  recorded 


WISEMAN  S   CASE. 


45 


by  Eicliard  Wiseman,  in  his  "  Chirurgical  Treatise  "  (1794), 
is  a  good  example.  Here  a  boy,  eight  years  old,  received 
such  a  blow  on  the  middle  of  his  face,  that  he  appeared  at  first 
dead,  and  afterwards  lay  in  a  prolonged  coma.  "  When  I 
first  saw  him,"  says  Wiseman,  ' '  he  presented  a  strange 
aspect,  having  his  face  driven  in,  his  lower  jaw  projecting 
forward ;  I  knew  not  where  to  find  any  purchase,  or  how  to 
make  any  extension.  But  after  a  time  he  became  sensible, 
and  was  persuaded  to  open  his  mouth.  I  saw  then  that 
the  bones  of  the  palate  were  driven  so  far  back  that  it  was 

Fig.  30. 


Illustration  of  the  gold  plate  or  splint ;  a,  b,  and  c  corresponding  to 
the  first  and  second  pre-molars  and  first  molar  respectively. 

impossible  to  pass  my  finger  behind  them,  as  I  had  intended, 
and  the  extension  could  be  made  in  no  other  way.  I  ex- 
temporised an  instrument,  curved  at  its  extremity,  which  I 
engaged  behind  the  palate,  and  having  carried  it  a  little 
upward  used  it  to  draw  the  bone  forward,  which  I  did  with- 
out any  difficulty  ;  but  I  had  hardly  withdrawn  the  instru- 
ment when  the  fractured  portions  went  back  again.  I  then 
contented  myself  with  dressing  the  face  with  an  astringent 
cerate  to  prevent  the  afflux  of  the  humours  ;  I  likewise 
prescribed  bleeding  ;  and  some  hours  afterwards  I  had  an 
instrument  better  constructed  to  reduce  the  large  mass  of 
displaced  bone  to  its  proper  position.  I  had  it  held  by  the 
child's  hand,  by  that  of  its  mother,  or  of  an  assistant,  each 
for  a  certain  time.  Nothing  else  was  done.  Thus  by  our 
united  attention  the  tonicity  of  the  parts  was  maintained  ; 
the  callus  was  developed,  and  in  proportion  as  it  became 


46  FRACTURE    OF    THE    UPPER    JAW. 

solidified  the  parts  became  stronger,  the  face  assumed  a  good 
appearance,  certainly  better  than  could  have  been  hoped  for 
after  such  marked  displacement,  and  the  child  was  entirely 
cured." 

The  most  frightful  injury  to  the  face  (except  from  gun- 
shot wounds)  I  ever  witnessed,  "was  from  the  passage  of 
a  waseon  wheel  over  the  face  of  a  man  who  fell  in  the 
street.  Here  the  bones  were  completely  shattered  and  the 
maxillte  were  torn  from  one  another,  and  death  was  instan- 
taneous. A  cast  of  this  frightful  deformity  is  in  the 
museum  of  the  Westminster  Hospital. 

A  case  very  nearly  as  desperate  at  first,  but  which 
fortunately  recovered,  was  admitted  into  the  same  hospital 
in  i860,  and  resulted  from  the  overturn  of  a  cab  upon  the 
face  of  its  fare,  who  at  the  moment  was  leaning  out  of 
window  to  direct  the  driver.  Here,  in  addition  to  a  frac- 
ture of  the  lower  jaw  a  little  to  the  left  of  the  median  line, 
there  were  two  fractures  of  the  superior  maxilla,  about  an 
inch  on  either  side  of  the  median  line  ;  the  nasal  bones 
were  broken ;  both  malar  bones  were  loose  and  separated 
from  their  attachments,  and  the  left  bone  was  fractured,  as 
also  the  external  angular  process  o£  the  frontal  bone. 
Though  not  positively  ascertained,  the  vomer  was  no  doubt 
fractured,  and  probably  the  vertical  plate  of  the  ethmoid  too. 
In  Dr.  Fyffe's  report  of  the  case  (Lancet,  July  i8th,  i860) 
which  I  can  confirm  by  personal  observation,  it  is  well 
noticed ;  "  It  was  remarkable  to  observe  how  movable  the 
bones  of  the  face  were.  On  watching  the  patient's  profile 
whilst  he  was  in  the  act  of  swallowing  food,  the  whole  of  the 
bones  of  the  face  were  observed  to  move  up  and  down  upon 
the  fixed  part  of  the  skull,  as  the  different  parts  were 
brought  into  motion  ;  it  appeared  as  if  the  integuments 
only  retained  them  in  their  position.  It  was  a  curious 
feature  in  the  case  that  notwithstanding  the  very  extensive 
injury  done,  and  the  violent  character  of  the  force  which 
caused  them,  not  a  single  tooth  was  fractured  or  misplaced."^ 
This  patient  made  a  perfect  recovery,  and  his  treatment  will 
be  alluded  to  under  another  section. 


guj^rin's  investigations.  47 

Fracture  of  tlie  upper  jaw  extending  into  the  antrum  may 
give  rise  to  subsequent  suppuration  in  that  cavity,  as 
remarked  by  Liston,  but  this  is  by  no  means  a  necessary 
consequence.  A  remarkable  case  of  transverse  fracture  of 
the  upper  jaw,  which  communicated  with  the  nose  and  with 
both  antra,  was  formerly  under  Mr.  Hutchinson's  care  in  the 
London  Hospital,  in  which  perfect  recovery  took  place  with- 
out exfoliation  of  any  part  of  the  bone,  although  the  alveolus 
containing  all  th«  teeth  was  completely  separated  and 
depressed  about  half  an  incli.  Here  the  injury  was  the 
result  of  a  "  jam "  between  a  "  lift "  and  a  cross-bar. 
{Medical  Circular^  February,  1867.)  A  very  similar  case 
occurred  to  Dr,  Guentha,  when  a  workman  was  struck  in  the 
face  by  the  angle  of  a  large  mass  of  stone.  Here  there  was 
complete  separation  of  the  alveolar  process  of  the  upper  jaw, 
the  entire  arch  in  an  unbroken  state  lying  on  the  lower  jaw, 
only  suspended  by  some  shreds  of  the  gum  and  soft  palate. 
This  man  also  made  a  perfect  recovery  {British  and  Foreign 
Quarterly  Review,  October,  i860).  In  the  summer  of  1871 
two  patients  were  admitted  into  University  College  Hospital 
within  a  few  hours  of  each  other,  in  both  of  whom  the 
superior  maxillae  were  fractured  and  freely  movable.  In 
one  case  perfect  recovery  ensued  and  death  in  the  other,  the 
post-mortem  examination  proving  that  there  was  no  injury 
to  the  base  of  the  skull. 

In  cases  such  as  these,  when  there  is  obvious  displace- 
ment, there  can  be  no  difficulty  in  the  diagnosis  of  the 
fracture,  but  cases  have  no  doubt  frequently  occurred  where 
a  fracture  without  displacement  has  been  overlooked.  Dr. 
A.  Guerin  has  elaborately  investigated  this  subject  {Archives 
G^n&cdes  de  MMecine,  July,  1866),  and  has  shown  from  a 
preparation  taken  from  a  fatal  case  and  from  experiments 
upon  the  dead  body,  that  violent  blows  below  the  orbits 
fraccure  not  only  the  maxillary  bones,  but  that  the  fracture 
usually  extends  to  the  vertical  portion  of  the  palate  bone 
and  the  pterygoid  process  of  the  sphenoid,  without  producing 
the  slightest  displacement.  The  diagnosis  of  the  injury 
cannot  be  established  by  any  external  manipulation,  but  by 


48  FPtACTURE    OF    THE    UPPER    JAW. 

carrying  the  finger  into  the  mouth  and  pressing  against  the 
internal  pterygoid  plate,  pain  will  be  produced  and  mobility 
of  the  process  will  be  ascertained.  The  diagnosis  was  con- 
firmed in  one  of  Dr.  Guerin's  cases  which  recovered,  by  an 
ecchymosis  beneath  the  mucous  membrane  of  the  palate.  In 
his  fatal  case  he  found  fracture  of  the  vertical  plate  of  the 
ethmoid,  in  addition  to  the  other  injuries. 

The  nasal  process  of  the  superior  maxilla  has  been  frac- 
tured by  blows  which  have  also  driven  in  the  nasal  bone, 
and  in  these  cases  emphysema  of  the  cellular  tissue  of  the 
face  is  not  uncommon,  and  is  best  checked  by  the  application 
of  collodion.  A  complication  of  this  form  of  fracture  which 
has  been  met  with,  is  permanent  obstruction  of  the  nasal 
duct,  leading  to  subsequent  troublesome  epiphora,  of  which 
I  have  seen  an  instance. 

Separation  of  the  two  maxillae  in  the  median  suture  has 
been  seen  in  cases  of  fatal  injury  to  the  face,  &c.,  on  many 
occasions,  but  Malgaigne  gives  a  case  of  the  kind  where  the 
patient  recovered.  The  patient,  a  man  aged  twenty-one, 
owing  to  a  fall  from  a  height  sustained,  in  addition  to  other 
injuries,  "  a  separation  of  the  upper  maxillary  and  palate 
bones  in  their  median  suture  to  the  extent  of  nine  milli- 
metres, with  depression  of  the  entire  left  side  of  the  face 
without  any  alteration  of  the  soft  parts."  The  parts  came 
together  spontaneously,  and  the  patient  recovered  without 
deformity. 

Hamilton,  however,  quotes  a  case  from  Harris,  of  New 
York,  in  which  a  child,  two  years  of  age,  had  separation  of 
the  maxillary  and  palate  bones  in  the  median  line,  the 
separation  being  sufficient  to  admit  the  little  finger,  and  here 
the  bones  were  still  open  six  weeks  after  the  accident. 

Com/plications. — The  teeth  of  the  upper  jaw  may  be  broken 
or  dislocated,  as  in  the  case  of  fracture  of  the  lower  jaw ; 
but  if  merely  loosened,  should  never  be  removed,  since  they 
will  probably  become  again  firmly  attached. 

Splintering  of  the  bone  is  much  more  common  in  the 
upper  than  the  lower  jaw,  particularly  after  gunshot  injuries 
and  here  modern  experience  has  shown  the  advisability  of 


TKEATMENT  OF  FRACTURE  OF  UITER  JAW.       49 

leaving  the  fragments  to  become  consolidated,  as  they  almost 
invariably  do,  and  the  non-necessity  for  the  performance 
of  dangerous  operations  of  resection  of  the  fragments — a 
subject  which  will  be  again  referred  to. 

Haemorrhage  is  much  more  frequent  and  copious  in  frac- 
tures of  the  upper  than  in  those  of  the  lower  jaw,  as  might 
be  anticipated  from  the  greater  vascularity  of  the  part.  A 
case  of  fracture  of  both  upper  and  lower  jaws,  where  pro- 
fuse haemorrhage  was  caused  by  division  of  the  facial  artery, 
has  been  already  referred  to,  but  the  hgemorrhage  not  un- 
frequently  comes  from  the  internal  maxillary  vessel  and  may 
be  immediately  fatal.  Secondary  hsemorrhage  in  case  of 
severe  injury  to  the  upper  jaw  is  by  no  means  uncommon, 
and  according  to  the  Surgeon-General  of  the  American 
Army  (Circular  No.  6,  Washington,  November  ist,  1865) 
was  the  principal  source  of  fatality  in  these  cases,  ligature  of 
the  carotid  artery  having  been  frequently  performed  with  the 
result  of  only  postponing  for  a  time  the  fatal  event. 

Nervous  Afedions. — Injury  to  the  infra-orbital  nerve  and 
its  branches  must  necessarily  ensue  in  cases  of  severe  frac- 
ture and  comminution  of  the  superior  maxilla,  and  consequent 
numbness  or  modification  of  sensation  will  be  the  result. 
A  lady,  recently  under  my  care,  who  fell  down  a  flight  of 
stairs  and  sustained  severe  injuries  to  the  head  and  face, 
although  no  fracture  of  the  jaw  could  be  detected,  suffers 
from  partial  anaesthesia  and  a  pricking  sensation  in  the  skin 
below  the  orbit.  Eobert  mentions  (Gazette  des  Hdpitaux, 
1859,  p.  157)  the  case  of  a  woman  who  was  run  over,  and 
sustained  a  fracture  with  permanent  paralysis  of  the  infra- 
orbital nerve.  Serious  brain  symptoms  may  ensue  when 
the  fracture  runs  back  to  the  sphenoid  bone  as  described  by 
M.  Guerin  (p.  47),  since  the  fissure  may  extend  to  the 
cranium,  and  this  is  especially  likely  to  happen  when  the 
whole  of  the  septum  narium  is  driven  back  with  the  jaws. 

Treatment  of  Fracture  of  the  Upper  Jaw. — Fractures  of 
the  upper  jaw  require  but  little  treatment  compared  with 
those  of  the  lower  jaw,  since  the  part  is  naturally  so  much 
more  fixed  that  there  is  little  difficulty  in  keeping  the  frag- 

D 


60  TRACTUEE    OF    THE    UPPER    JAW. 

ments  in  position.  The  hifimorrhage,  which  is  often  free, 
must  be  arrested  by  cold,  the  application  of  styptics,  and,  as 
a  last  resource,  the  actual  cautery.  The  operation  of  deli- 
gation  of  the  carotid  artery  in  these  cases  has  yielded  such 
unsatisfactory  results  as  to  render  the  surgeon  unwilling  to 
resort  to  it  except  under  the  most  desperate  circumstances, 
and  he  would  in  my  opinion  be  justified  in  laying  open  the 
face  and  removing  large  fragments  of  bone  so  as  to  apply 
the  cautery  more  satisfactorily,  rather  than  resort  to  a  dan- 
gerous and  doubtful  operation.  When,  as  is  most  commonly 
the  case,  the  soft  tissues  of  the  face  are  lacerated  and  the 
haemorrhage  arises  from  them,  the  bleeding  vessels  must  be 
secured  with  ligatures  in  the  ordinary  manner. 

All  authorities  are  agreed  as  to  the  non-advisability  of 
removing  the  fragments  of  a  broken  upper  jaw,  since,  owing 
to  the  vascularity  of  the  part,  they  almost  invariably  unite 
readily.  Malgaigne  says :  "  In  common  fractures  of  the 
upper  jaw  there  is  one  principle  which  surgeons  cannot  too 
carefully  bear  in  mind — that  is,  that  all  splinters,  however 
slightly  adherent,  should  be  scrupulously  preserved,  as  they 
become  reunited  with  wonderful  facility.  This  remark  was 
made  by  Saviard  ;  Larrey  has  strongly  insisted  on  it,  and  we 
have  seen  that  M.  Baudens,  who  so  much  urges  the  extrac- 
tion of  splinters,  has  likewise  made  a  special  exception  of 
these  cases"  (Packard's  translation,  p.  304).  Hamilton 
remarks  that  the  experience  of  American  surgeons  during 
the  war  confirms  these  observations.  "  Owing  to  the  extreme 
vascularity  of  the  bones  composing  the  upper  jaw,  the  frag- 
ments have  been  found  to  unite  after  the  most  severe  gun- 
shot injuries  with  surprising  rapidity,  the  amount  of  necrosis 
and  caries  being  usually  inconsiderable  compared  with  the 
amount  of  comminution  "  (p.  106). 

Notwithstanding  this,  however,  Hamilton  gives  a  lengthy 
account  of  a  case  of  fracture  of  the  upper  jaw,  in  which  he, 
in  conjunction  with  Dr.  Potter,  thought  it  necessary  to 
remove  a  fragment,  which  included  the  floor  of  the  antrum 
and  had  been  drawn  down  and  displaced  in  an  attempt  to 
extract  a  loose  tooth.     "  The  time  occupied  in  this  operation 


METHODS    OF    TKEATMENT.  51 

was  at  least  one  hour,  during  which  we  were  every  moment 
in  the  most  painful  apprehension  lest  we  should  reach  and 
wound  the  internal  carotid  artery,  which  lay  in  such  close 
juxtaposition  to  the  knife  that  we  could  distinctly  feel  its 
pulsation.  After  its  removal  the  haemorrhage  was  for  an 
hour  or  more  quite  profuse,  and  could  only  be  restrained  by 
sponge  compresses  pressed  firmly  back  into  the  mouth  and 
antrum  "  (p.  103).  Such  dangerous  operations  are  much  to 
be  deprecated,  and  cases  already  quoted  prove  that  even  after 
greater  separation  the  bone  will  thoroughly  reunite. 

Mention  has  been  made  of  the  difficulty  Wiseman  ex- 
perienced in  reducing  the  fragments  to  their  proper  position 
in  his  case,  and  the  means  he  adopted  to  overcome  it.  In 
the  majority  of  cases  the  finger  introduced  into  the  mouth 
and  passed  around  the  alveoli  will  readily  restore  any  irre- 
gularity, being  aided,  if  necessary,  by  the  introduction  of  a 
strong  elevator  or  pair  of  dressing  forceps  into  the  nostril. 
The  teeth  in  adjacent  fragments  may  be  advantageously 
wired  together  to  keep  them  in  position,  or,  where  there  is 
great  comminution  and  irregularity  of  the  alveoli,  a  piece  of 
soft  gutta-percha  may  be  adapted  to  them  so  as  to  hold  and 
support  the  fragments.  The  lower  teeth  should  not  be 
allowed  to  come  in  contact  with  this  until  it  is  thoroughly 
hardened,  or  they  would  become  imbedded  and  thus  cause 
its  displacement.  In  very  complicated  cases,  as  in  examples 
of  fractures  of  both  jaws,  the  vulcanite  interdental  splints 
of  Mr.  Gunning  (described  under  Fractures  of  the  Lower 
Jaw)  might  be  employed,  these  having  an  aperture  for  the 
introduction  of  food. 

Graefe  employed  an  apparatus,  of  which  the  following 
description  is  given  by  Malgaigae  (Packard's  translation, 
p.  30 1)  :  "A  curved  steel  spring,  properly  padded,  is  applied 
over  the  forehead,  and  kept  in  place  by  a  strap  buckled 
around  the  occiput.  This  steel  has  at  each  side  a  hole  with 
a  screw,  for  making  pressure  ;  and  a  steel  brace  to  which  it 
affords  a  point  d'appui,  for  acting  steadily  on  the  dental 
arch.  Now  these  braces,  descending  to  the  level  of  the  free 
edge  of  the  upper  lip,  curve  backward  so  as  to  go  around 


52  FRACTUEE    OF    THE    UPPER    JAW. 

the  lip  without  wounding  it;  getting  thus  at  the  dental 
arch,  they  again  curve  so  as  to  apply  themselves  to  it.  But 
as  the  pressure  of  the  braces  should  have  the  effect  of  keep- 
ing the  detached  teeth  in  proper  relation  with  the  rest,  a 
silver  trough  duly  padded  is  made  to  fit  over  both  to  a 
sufficient  length  ;  and  upon  this  trough  the  braces  exert 
their  pressure.  It  is  easy  to  see  how,  by  altering  their 
height  as  regards  the  spring  over  the  forehead,  the  pressure 
may  be  regulated  to  the  right  degree." 

A  somewhat  similar  apparatus,  but  with  the  addition  of 
a  pad  which  can  be  applied  externally  so  as  to  support  the 
cheek,  was  brought  before  the  Surgical  Society  of  Paris,  in 
September,  1862,  by  M.  Goffres. 

In  the  rare  cases  of  separation  of  the  maxillae,  a  spring 
passing  behind  the  head  and  making  pressure  upon  the 
maxillae,  after  the  manner  of  Hainsby's  hare-lip  apparatus, 
might  be  advantageously  employed. 


CHAPTEK  V. 

GUNSHOT   INJURIES   OF   THE   JAWS. 

OuNSHOT  injuries  of  the  jaws  have  necessarily  been  inci- 
dentally referred  to  in  considering  fractures  of  those  bones 
separately,  but  it  will  be  convenient  to  class  the  injuries  of 
the  two  maxillse  by  fire-arms  together,  since  these  accidents 
affect  both  bones  in  the  majority  of  cases.  Laceration  of 
the  soft  tissues  and  consequent  haemorrhage  are  almost  con- 
stant accompaniments  of  wounds  of  the  face,  and  the  mortality 
attending  them  is  high,  both  from  the  immediate  effects  of 
the  injury,  and  from  the  frequent  occurrence  of  secondary 
haemorrhage.  The  effects  of  the  modern  arms  of  precision 
contrast  unfavourably  in  this  respect  with  those  of  the 
round  bullet  of  the  old  fire-lock,  for  though  the  latter  fre- 
quently lodged  in  one  of  the  cavities  of  the  face  for  an 
indefinite  time,  the  irregular  mass  of  metal  driven  with 
tremendous  velocity  by  the  modern  rifle  commits  greater 
havoc,  splintering  the  bones  and  lacerating  the  soft  tissues 
most  extensively. 

The  Surgeon- General  of  the  American  army  reported  in 
November  1865  (Circular  No.  6,  Washington),  that  from 
the  commencement  of  the  war  to  October,  1864,  of  4167 
wounds  of  the  face  reported  to  him,  there  were  15  79  frac- 
tures of  the  facial  bones;  and  of  these  891  recovered  and 
171  died,  showing  a  mortality  of  11  per  cent. — the 
terminations  being  still  to  be  ascertained  in  517  cases. 
Secondary  haemorrhage  was  the  principal  cause  of  mortality 
in  these  cases,  and  the  carotid  had  frequently  been  tied  with 
the  result  of  postponing  for  a  time  the  fatal  result. 

The  Crimean  returns  from  the  i  st  of  April,  1855  to  the 


54 


GUNSHOT    INJUEIES    OF   THE   JAWS. 


end  of  the  war,  show  533  wounds  of  the  face,  of  which  the 
bones  were  injured  in  107  instances;  445  patients  returned 
to  duty,  74  were  invalided,  and  14  died. 

Here  the  mortality  was  about  1 3  per  cent. 

The  following  table  is  compiled  from  the  experience  of 
the  Franco-Prussian  war  of  1870-71.  Here  the  mortality 
was  only  about  8  per  cent,  among  the  German  troops  : 

Ghinshot  Wounds  of  Face  in  Franco- Prussian  War, 
1870-71.     {German  troops.) 


Total  Number 
of  Cases. 

Deaths. 

Percentage 
Death-rate. 

A.  Soft  parts  of  face    . 

647 

7 

1 

B.  Bones  of  face  . 

1422 

104 

8 

B.  Bones  of  Face. 

Total  Number 
of  Cases. 

Deaths. 

Percentage 
Death-rate. 

Upper  jaw    .... 
Lower  jaw    .... 
Upper  and  lower  jaw  together 
Nasal  bones .... 
Malar  bones 

Palate 

Lachrymal   .... 
Vomer           .... 

789 

400 

66 

8q 

64 
) 

58 

35 

8 

0 

3 

0 

8 

9-3 

13-8 

0 

5 
0 

It  must  be  remembered  that  in  all  these  wars  antiseptic 
methods  of  treating  wounds  were  not  employed,  and  a  large 
proportion  of  the  deaths  was  due  to  septic  processes  taking 
place  both  inside  and  outside  the  mouth.  Then,  again, 
secondary  hsemorrhage,  a  not  infrequent  cause  of  death  in 
the  past,  occurs  but  rarely  after  surgical  operations  upon,  or 
wounds  of  the  jaws,  at  the  present  day.  There  is  every 
reason  to  hope,  therefore,  that  in  any  future  war  the  death 
rate  after  gun-shot  wounds  of  the  jaws  would  be  much 
smaller  than  8  per  cent. 

Wounds  of  Upper  Jaiv. — In  nearly  all  cases  of  gunshot 
wounds  of  the  upper  jaw,  the  soft  parts  of   the   face   are 


FOREIGN   BODIES   LODGED.  55 

wounded  as  well.    The  only  exception  is  in  the  case  of  suicidal 
wounds,  where  the  weapon  is  fired  through  the  open  mouth. 

In  some  cases  the  injury  is  limited  to  the  upper  jaw  ana 
the  soft  parts  covering  it,  but  very  often  the  injury  is  much 
more  extensive,  involving  the  greater  part  of  the  face,  the 
nasal  and  orbital  fossae,  or  even  the  cranial  cavity. 

When  the  injury  is  limited  to  the  upper  jaw,  the  alveolar 
process  and  the  antrum  are  the  parts  usually  involved,  but 
sometimes  the  palate  may  be  affected.  Thus,  Mr.  Cox  Smith, 
of  Chatham,  records  the  case  of  a  soldier  who  came  under 
his  care,  in  whom  the  jaw  and  palate  had  been  extensively 
fractured  and  the  incisor  teeth  driven  in,  so  that  the  patient 
was  unable  to  masticate  or  speak.  By  extracting  these  teeth, 
Mr.  Smith  was  able  to  adapt  a  set  of  artificial  teeth,  so  as  to 
restore  to  the  patient  the  use  of  his  mouth  for  all  purposes. 

Missiles,  striking  from  without,  occasionally  lodge  for  a 
considerable  time  in  the  antrum  or  nose,  and  sometimes 
without  their  presence  being  suspected.  In  the  "  Medical 
and  Surgical  History  of  the  Crimean  War  "  will  be  found 
the  case  of  a  soldier  who  received  a  severe  wound  of  the 
face.  A  grapeshot,  weighing  seventeen  ounces,  lodged  in 
the  jaw,  having  displaced  the  palate,  with  a  portion  of  the 
maxilla  and  all  the  molar  teeth  of  the  right  side,  into  the 
mouth.  Here  it  was  found  necessary  to  enlarge  the  wound 
and  remove  the  fragments  (contrary  to  the  general  rule  of 
practice)  before  the  ball  could  be  extracted,  but  the  patient 
made  a  good  recovery,  notwithstanding  severe  secondary 
haemorrhage.  Still  more  remarkable,  how^ever,  are  cases 
which  have  occurred  in  civil  practice,  where  the  breech  of 
a  burst  fowling-piece  has  lodged  for  years  in  the  antrum. 
A  remarkable  case  of  this  kind  was  reported  in  the  ^dinhurgh 
Medical  Journal,  of  September,  1856,  by  Dr.  Fraser,  of  New- 
foundland, who  removed  a  piece  of  metal,  weighing  more 
than  four  ounces,  and  measuring  nearly  three  inches  in 
length,  from  the  jaw  of  a  man  who  had  sustained  an  acci- 
dent seven  years  before.  A  still  more  extraordinary  case  is 
recorded  in  the  Museum  of  Guy's  Hospital,  which  possesses 
a  model  of  the  breech  of  a  gun  which  had  been  lodged  in 


56  GUNSHOT   INJUEIES    OF    THE    JAWS. 

the  face  of  a  man  for  twenty-one  years  !  "  The  patient 
was  shooting  birds  when  the  gun  burst,  the  right  eye  was 
knocked  out  and  the  roof  of  the  orbit  destroyed,  and  through. 
it  the  brain  protruded  ;  the  latter  sloughed,  and,  after  a  long 
illness,  the  man  recovered.  At  the  latter  end  of  1856  he 
was  suddenly  seized  with  symptoms  of  choking,  as  from  a 
foreign  body  in  the  throat,  and,  on  putting  his  finger  in  his 
mouth  to  remove  it,  he  drew  forth  the  breech  of  a  gun, 
much  oxidised  and  covered  with  purulent  matter.  It  is 
supposed  that  the  piece  of  iron  broke  through  the  floor  of 
the  orbit,  and  had  been  lodging  in  the  antrum  ever  since." 

In  connection  with  this  subject  may  be  mentioned  the 
case  of  a  knife-blade  lodged  in  the  antrum  for  forty-two 
years,  and  finally  coming  out  of  the  nostril,  reported  in  the 
Bulletino  di  Bologna,  May,  1864. 

Gunshot  wounds  of  the  upper  jaw  through  the  mouth 
are  usually  of  suicidal  origin,  and  of  this  a  specimen,  pre- 
sented by  myself,  is  now  in  the  Museum  of  the  College  of 
Surgeons,  being  the  skull  of  a  man  who  fired  a  pistol 
into  his  mouth.  The  red  lines  on  the  preparation  mark  the 
outline  of  the  fracture,  and  it  will  be  seen  that  a  great  part 
of  the  hard  palate  was  driven  in,  and  that  the  bullet,  after 
fracturing  extensively  the  base  of  the  skull,  carried  away  a 
considerable  portion  of  the  vault  of  the  cranium.  The  malar 
bone,  with  the  outer  wall  of  the  antrum,  is  broken  off  on  the 
right  side,  and  the  malar  bone  on  the  left  is  separated  from 
the  maxilla  at  the  articulation.  In  a  second  case  of  the 
kind,  which  I  also  had  the  opportunity  of  examining  imme- 
diately after  death,  the  injuries  were  similar  in  extent. 

In  the  preparation  referred  to  there  is  an  oblique  fracture 
of  the  lower  jaw  on  the  left  side,  running  backwards  through 
the  socket  of  the  first  molar  tooth,  and  an  oblique  crack  has 
been  produced  on  the  inner  surface  of  the  right  side  of  the 
bone,  in  an  exactly  corresponding  position.  Fracture  of  the 
jaw  had  occurred  also  in  the  second  case  alluded  to,  and  has 
been  frequently  noticed  under  similar  circumstances,  the 
fracture  depending  upon  the  concussion  of  the  explosion 
and  the  rapid  development  of  gas  within  the  mouth.     This 


FOREIGN    BODIES    LODGED.  57 

is  not  without  exception,  however,  since,  in  the  University 
College  Museum,  there  is  the  skull  of  a  man  who  fired 
a  pistol  into  his  mouth,  in  which  the  palate  is  extensively 
damaged,  but  the  lower  jaw  perfect.  When  the  bullet 
actually  enters  the  mouth  the  injury  is  usually  immediately 
fatal,  but  Otto  Weber  has  recorded  {Handhuch  cler  Allge- 
meinen  unci  Specidlen  Chiriirgic,  Part  III.,  1866)  a  case  of 
recovery  : — "  The  patient,  through  despair  arising  from  pecu- 
niary embarrassments,  determined  to  shoot  himself  in  the 
churchyard.  He  held  the  pistol  before  his  open  mouth, 
and,  after  firing,  fell  senseless  to  the  ground.  After  some 
time  he  came  to  himself,  looked  for  his  spectacles,  which 
had  fallen  off  his  face,  and  made  the  gravedigger  bring  him 
to  me.  The  palatal  vault  was  simply  perforated,  and  the 
ball,  completely  flattened,  was  sticking  in  the  body  of  the 
sphenoid  bone,  where  it  could  be  felt  by  the  index  finger 
introduced  into  the  hole  by  which  it  had  entered.  After 
some  fruitless  attempts  to  extract  it,  it  fell  into  the  patient's 
throat  and  he  spat  it  out.  Subsequently  the  hole  in  the 
palate  completely  closed  up  again,  and  the  patient  recovered 
both  physically  and  morally,"  In  this  case  the  lower  jaw 
does  not  appear  to  have  suffered,  but  Mr.  Barrett  has  shown 
me  the  model  of  a  case  in  which  a  pistol  bullet,  fired  at  the 
open  mouth,  glanced  off  an  incisor  tooth,  and  ran  up  the 
side  of  the  face,  emerging  near  the  malar  bone,  and  where 
nevertheless  the  lower  jaw  was  broken  by  the  explosion. 

I  was  once  called  in  by  Dr.  Whitmarsh,  of  Hounslow,  to 
see  a  patient  who  had  fired  a  pistol,  loaded  with  small  shot, 
into  his  mouth,  smashing  the  palate  and  fracturing  the  lower 
jaw  in  two  places  by  the  explosion,  but  who  eventually  made 
a  good  recovery;  and  in  the  Lancet,  Nov.  7th,  1868,  will 
be  found  a  remarkable  case  under  the  care  of  Mr.  Sydnev 
Jones,  of  recovery  after  a  similar  injury,  complicated  by 
division  of  one  optic  nerve  and  injury  to  the  brain. 

Because  a  bullet  has  entered  the  mouth,  and  inflicted 
injury  upon  the  bones  of  the  palate,  &c.,  it  does  not  neces- 
sarily lodge  there  ;  thus,  in  the  "  Medical  and  Surgical 
History  of  the  Crimea,"  is  the  case  of  John   Collins,  97th 


58  GUNSHOT   INJUEIES    OF    THE    JAWS. 

Eeginient,  who  was  wounded  on  Sept.  8  th  and  sent  to 
hospital  on  the  14th,  having  been  struck  by  a  musket-ball, 
which  had  entered  the  mouth,  slightly  cutting  the  upper 
lip,  and  had  comminuted  the  palate  plate  of  the  superior 
maxilla,  and  appeared  to  be  lodged  somewhere  among  the 
ethmoid  cells.  There  was  but  little  constitutional  disturb- 
ance. All  the  incisor  teeth  of  the  upper  jaw  became  dead, 
and  had  to  be  removed,  as  well  as  some  fragments  of  the 
palate  plate,  but  the  wound  slowly  healed  and  finally  filled 
up,  leaving  the  man  but  little  the  worse,  except  for  the  loss 
of  his  teeth.  Various  careful  examinations,  made  at  different 
times,  failed  to  detect  the  presence  of  any  foreign  body,  and 
the  man  himself  afterwards  stated  that  he  had  always  fancied 
the  bullet  fell  out  during  his  progress  from  the  trenches  to 
the  regimental  hospital. 

Complications  of  gunshot  wounds  of  the  upper  jaw  may 
be  divided  into  immediate  and  remote.  The  most  serious 
immediate  complication  is  haemorrhage,  which  usually  takes 
place  from  the  internal  maxillary  artery.  The  next,  in 
order  of  severity,  is  suppuration,  both  intra-  and  extra-buccal. 
One  of  the  gravest  dangers  in  suppuration  is  the  poisoning 
produced  by  the  constant  swallowing  of  foul  pus.  By  the 
assiduous  use  of  antiseptics  this  danger  can  be  much 
lessened. 

Other  less  important  complications  are  injuries  to  branches 
of  the  facial  nerve  or  of  the  infra-orbital  nerve.  In  some 
cases  Stenson's  duct  is  wounded,  and  may  cause  trouble  by 
the  salivary  fistula  that  forms. 

In  an  interesting  paper  by  Dr.  Ludwig  Brandt  {Beitrdge 
zer  Belicmdhmg  der  Schussverldzungcn  der  Kiefer  %ind 
deren  henaclibciTten  Weiclitlieile.  Berlin,  1892)  it  is  pointed 
out  that  a  very  frequent  result  of  gunshot  wounds  of 
the  upper  jaw  is  deficient  mobility  of  the  lower  jaw,  the 
condition  known  as  "  closure  of  the  jaws "  (chap,  xxvii). 
This  fixation  of  the  lower  jaw  is  brought  about  by  the 
healing  of  extensive  wounds  of  the  mucous  membrane 
of  the  mouth  or  of  the  external  soft  parts.  The  con- 
traction   of   the    cicatricial  tissue  draws  the  lower  jaw  up 


WOUNDS    OF    THE   LOWER   JAW.  O^ 

towards  the  upper  jaw  and  prevents  the  proper  opening  of 
the  mouth. 

We  may  say  that  this  is  the  most  serious  remote  com- 
plication of  gunshot  wounds  of  the  upper  jaw. 

Wounds  of  the  Loicer  Jaw. — Fracture  of  the  lower  jaw 
alone  may  be  produced  by  bullets,  and  in  this  case  the 
hfemorrhage  is  often  severe  from  the  divided  facial  artery, 
which  vessel  is  generally  involved.  In  the  Edinhurgh 
Medical  Journal,  September,  i860,  Dr.  John  Brown,  of  the 
Bengal  Medical  Service,  records  four  cases  of  the  kind, 
which  are  good  examples  of  the  variety  of  injury  inflicted 
by  a  bullet  : 

1 .  Was  a  gunshot  injury  of  the  jaw,  attended  by  profuse 
haemorrhage.  The  facial  artery  was  secured,  and  a  large  por- 
tion of  the  comminuted  bone  removed.    The  patient  did  well. 

2.  Was  a  gunshot  wound  at  the  symphysis.  There  was 
a  depression  in  the  bone  at  the  spot,  but  the  ball  had  not 
perforated  it.     Did  well. 

3.  Occurred  in  Lucknow.  A  Sikh  was  shot  in  the  right 
side  of  the  lower  jaw ;  there  was  great  arterial  hsemorrhage 
from  the  facial  artery,  with  a  small  wound  over  the  angle 
and  a  larger  one  over  the  symphysis.  Both  were  laid  into 
one,  fragments  were  removed,  and  the  facial  artery  tied. 
Died  on  twelfth  day. 

4.  Ball  traversed  the  mouth  and  fractured  both  sides  of 
the  lower  jaw  near  the  angles.  Died  from  pyaemia  on 
twenty- first  day. 

The  catalogue  of  the  Surgical  Section  of  the  United 
States  Army  Medical  Museum  (1866)  contains  numerous 
records  of  injuries  of  this  kind,  from  which  the  following 
may  be  quoted  as  most  remarkable  : 

"3350.  The  right  half  of  the  inferior  maxilla  fractured 
by  a  musket-ball,  a  small  portion  of  which  is  attached. 
The  missile  entered  the  mouth,  struck  the  alveolar  ridge 
at  the  molar  teeth,  comminuting  it,  and  causing  oblique 
fracture  of  the  body  of  the  bone.  The  patient  died  the 
same  day  from  haemorrhage,  from  rupture  of  the  internal 
maxillary  artery. 


60  GUNSHOT   INJURIES    OF    THE  JAWS. 

"  145  I.  Wet  preparation  of  the  right  side  of  the  body  of 
the  inferior  maxilla,  fractured  and  comminuted  hy  a  mnsket- 
ball  at  the  angle.  A  fragment  containing  the  molar  teeth 
is  driven  inward,  and  other  fragments  remain  in  situ,  the 
total  amount  of  bone  shattered  being  two  inches.  The  ball 
lodged  in  the  thyroid  cartilage,  causing  death  by  suffocation 
on  the  nineteenth  day. 

"  3542.  The  inferior  maxilla  fractured  and  comminuted 
by  a  musket-ball.  The  alveolar  ridge  and  the  teeth  are 
entirely  removed ;  there  is  a  horizontal  fracture  of  the  left 
ramus  passing  through  the  inferior  dental  foramen ;  on  the 
right  side  there  is  a  transverse  fracture  of  the  body  of  the 
bone  at  the  last  molar,  and  an  oblique  vertical  fracture  at 
the  symphysis.  The  patient  died  from  the  effect  of  the 
wound  of  the  tongue,  causing  haemorrhage,  for  which  the 
left  common  carotid  was  ligated." 

A  fracture  may  possibly  be  produced  indirectly  without 
the  bullet  actually  striking  the  jaw ;  of  this  the  following 
extraordinary  instance  occurred  at  the  battle  of  Balaclava. 
A  man  of  the  4th  Light  Dragoons  received  a  compound 
fracture  of  the  lower  jaw  by  a  grape-shot  striking  the  flat 
of  his  sabre,  while  at  the  slope,  and  driving  it  against  the 
side  of  his  face  and  head.  The  blade  was  bent,  but  not 
broken,  and  the  missile  did  not  touch  the  man. 

Fragments  of  the  jaw  have  been  driven  into  other  parts 
of  the  body,  and  even  into  that  of  a  neighbour.  In  the 
"  Medical  and  Surgical  History  of  the  Crimean  War  "  is 
reported  the  case  of  a  soldier  who  was  shot  in  the  right 
cheek,  the  ball  glancing  downwards  and  lodging  in  the  neck, 
from  which  it  was  extracted.  Subsequently  a  foreign  body 
was  detected  behind  the  right  clavicle,  which  was  cut  down 
upon  and  proved  to  be  a  portion  of  the  lower  jaw. 
Hamilton,  also,  in  his  "  Military  Surgery  "  (p.  255),  mentions 
the  case  of  a  Confederate  soldier,  who  was  kneeling  and 
bending  forward  when  he  received  a  riiie  ball  upon  his  four 
lower  incisor  teeth.  The  ball  and  teeth  disappeared,  but 
were  subsequently  removed  from  beneath  the  skin  at  the 
top  of  the  sternum. 


LATER    COMPLICATIONS.  61 

As  in  the  case  of  the  upper  jaw,  the  most  serious 
immediate  complication  of  gunshot  wounds  of  the  lower  jaw 
is  hcTemorrhage.  It  has  been  already  mentioned  that  this 
frequently  takes  place  from  the  facial  artery,  but  it  may  also 
take  place  from  the  inferior  dental,  lingual,  or  transverse  facial 
vessels.  In  the  American  war  it  was  especially  noted  that 
by  no  means  infrequently  the  carotid  vessels  were  wounded. 

Septic  inflammation  again,  occurring  after  wounds  of  the 
lower  jaw,  may  be  just  as  serious  as  in  the  case  of  the  upper 
jaw. 

When  the  middle  part  of  the  lower  jaw  is  fractured,  the 
tongue  tends  to  fall  backwards,  and  may  cause  asphyxia. 
This  can  be  easily  prevented  by  passing  a  ligature  through 
the  tongue,  and  so  fixing  it  that  the  tongue  is  prevented  from 
falling  backwards. 

Further,  branches  of  the  facial  or  trigeminal  nerve  may 
be  divided,  causing  varying  degrees  of  motor  paralysis  or  of 
anaesthesia. 

As  regards  the  later  complications,  one  of  frequent 
occurrence  is  the  formation  of  a  false  joint  after  gunshot 
injuries  of  the  lower  jaw,  which  has  been  already  adverted 
to  in  the  section  upon  False  Joint. 

Another  important  result  is  that  the  muscles  have 
a  constant  tendency  to  draw  the  two  sides  of  the  jaw 
together.  Not  only  is  this  effect  produced  upon  the  lower 
jaw,  but  there  appears  to  be  a  secondary  effect  produced  in 
these  cases  upon  the  upper  jaw,  the  alveolar  arch  of  which 
becomes  gradually  contracted  from  want  of  proper 
antagonism.  M.  Debout,  in  the  paper  already  referred  to, 
gives  the  case  of  a  French  corporal,  who,  during  the  Italian 
campaign,  was  wounded  by  a  fragment  of  shell,  vv'hich 
fractured  the  lower  jaw  and  severely  lacerated  the  integu- 
ments. The  comminuted  fragments  were  removed,  and  the 
soft  parts  brought  together  with  sutures,  so  as  to  restore  as 
far  as  possible  the  floor  of  the  mouth.  All  that  could  be 
obtained,  however,  was  to  form  a  sort  of  channel  concealed 
by  the  beard,  as  shown  in  Fig,  3 1 ,  by  which  the  saliva 
fl.owed  in  great  abundance. 


62  GUNSHOT    INJURIES    OF    THE    JAWS. 

Complete  or  nearly  complete  destruction  of  the  lower  jaw 
by  a  cannon-ball  has  more  than  once  occurred,  the  patients 
surviving  for  many  years,  and  the  deformity  being  palliated 
by  the  use  of  a  silver  chin  (Fig.  32).  The  accompanying 
illustration  (Fig.  33)  from  M.  Debout's  paper,  shows  the 
dissection  of  a  case  of  the  kind  more  than  thirty  years  after 
the  receipt  of  the  injury,  the  history  being  as  follows : — At 
the  battle  of  Jena,  Vernet  had  the  body  and  left  ramus  of 


Fig. 


the  lower  jaw  carried  away  by  a  cannon-ball.  The  soft 
parts,  bruised  and  torn,  hung  down  in  front  of  the  neck, 
and  the  tongue  was  much  injured  from  the  tip  along  the 
left  side.  At  the  ambulance  the  parts  were  adjusted  as  well 
as  possible,  and  the  dressing  completed.  An  abundant 
suppuration  ensued ;  splinters  were  detached  from  the 
extremities  of  the  bones,  and  the  whole  was  healed  in 
three  months. 

Eibes,  in  18 18,  described  thus  the  condition  of  the  parts 
when  Vernet  had  attained  the  age  of  forty-four: — "The  soft 


KESULTS    OF    HEALING. 


63 


parts  and  loose   flaps   of    the   lips,  chin,  and  cheeks   have 
become  agglutinated  at  the  upper  part  of  the  neck,  above 

Fio.  32. 


and  to  the  side  of  the  larynx  at  the  root  of  the  tongue, 
where  they  form  by  their  adhesion  divers  folds  and  cicatrices. 

Fig.  33. 


The  opening — the  mouth — ^is  situated  beneath  the  arch  of 
the  palate ;  the  tongue  lies  concealed  in  the  soft  parts,  and 


64  GUNSHOT   I2SIJURIES    OF   THE    JAWS. 

retracted  towards  the  pharynx  ;  the  lower  part  of  the  tongue 
is  closely  adherent,  and  in  a  manner  fixed  to  the  parts 
beneath  it,  so  that  the  tip  can  be  projected  only  to  the  left 
and  not  forwards. 

"  The  patient  wears  a  silver  double  chin,  with  which  he 
can  speak  pretty  distinctly ;  but  is  much  inconvenienced  by 
the  incessant  escape  of  the  saliva." — Did.  des  Sciences 
MMicales,  tom.  xxix,  p.  425. 

Vernet  lived  twenty  years  longer ;  and  some  years  before 
his  death  the  mouth-opening  became  so  narrow  that,  instead 
of  being  obliged  to  change  the  cloths  or  sponges,  into  which 
the  saliva  used  to  flow,  five  or  six  times  a  day,  he  scarcely 
wetted  one. 

In  this  case  the  steady  contraction  of  the  cicatricial 
tissues  of  the  mouth  had  a  beneficial  tendency.  The  effect 
produced  upon  the  teeth  of  the  upper  jaw  is  well  seen  in 
the  illustration. 

As  in  the  case  of  the  upper  jaw,  injuries  of  the  lower  jaw 
may  be  followed  by  the  condition  known  as  "  closure  of  the 
jaws."  This  may  be  due  either  to  ankylosis  of  the  temporo- 
maxillary  joint  or  to  the  formation  of  cicatricial  bands, 
already  described  in  wounds  of  the  upper  jaw. 

Another  very  serious  complication  of  gunshot  wounds  of 
the  lower  jaw  is  injury  to  the  lower  lip,  which  may  cause 
difficulty  in  speaking,  in  eating,  &c.,  and  in  addition  the 
saliva  may  be  constantly  escaping  from  the  mouth. 

Wounds  of  Upper  and  Lower  Javjs.  —  Cannon  shot, 
striking  the  face,  inflict  the  most  frightful  injuries  upon  the 
jaws,  which  are  usually  fatal;  thus,  Professor  Longmore 
mentions  ("  System  of  Surgery,"  vol.  i)  the  case  of  an  officer 
of  Zouaves  in  the  Crimea,  who  had  the  whole  face  and  jaw 
carried  away  by  a  cannon-ball,  the  eyes  and  tongue  being 
included,  so  that  there  remained  only  the  cranium.  The 
patient  survived  for  twenty  hours.  Gruthrie  also  relates  a 
very  similar  case,  as  having  occurred  at  the  siege  of  Badajos. 
The  wars  of  the  first  Napoleon  afforded  some  frightful 
examples  of  injury  to  the  jaws,  which  the  unfortunate 
patients  survived  for  years  in  one  of  the  military  asylums  of 


INJUEY    FROM    CANNOX-BALL. 


65 


Paris.  The  accompanying  drawing  (Fig.  34),  taken  from  an 
able  paper  by  M.  Emile  Debout,  "  On  the  Mechanical 
liestoration  of  the  Maxillas "  {British  Journal  of  Dental 
Science,  April,  1864),  shows  the  condition  of  a  corporal  who 
was  strnck  by  a  cannon-ball  at  the  siege  of  Alexandria,  in 
1800.  The  shot  carried  away  the  greater  part  of  the  face, 
including  three-fourths  of  the  lower  jaw  and  part  of  the 

Fid.  34. 


tongue,  and  the  man  was  thought  to  be  dead.  Under  the 
solicitous  care  of  Baron  Larrey  he  recovered  liowever,  and 
lived  for  more  than  twenty  years.  "  It  can  be  seen  at  a 
glance  that  speech  and  mastication  were  impossible.  Poor 
Vaute  concealed  the  deformity  by  wearing  a  mask,  gilt 
inside,  and  imitating  the  colour  of  the  skin  outside.  He 
could  even  by  means  of  this  cover  make  himself  a  little 
understood,  but  his  greatest  distress  arose  from  the  incessant 
escape  of  the  saliva,  whicli  was  so  great  as  to  saturate  in 
succession  a  number  of  linen  compresses  in  the  course  of  the 

E 


6Q  GUNSHOT    INJURIES    OF    THE    JAWS. 

day.  After  supporting  his  misfortune  heroically  for  so  many 
years,  he  put  an  end  to  his  misery  in  1 8  2  i .  In  order  to 
complete  the  history  of  a  case  in  which  he  had  felt  so  deep 
an  interest,  Larrey,  on  learning  the  death  of  Vaute,  procured 
his  head,  the  state  of  which  he  described. 

"  The  loss  of  substance  occasioned  by  the  ball  was  limited 
to  the  elliptic  segment  seen  in  the  portrait.  The  left  malar 
bone  had  been  carrried  away.  The  arch  of  the  palate  and 
the  nasal  fossse  down  to  the  ethmoid  had  been  destroyed. 
The  inferior  and  internal  orbital  walls,  down  to  the  base  of 
the  skull,  had  been  also  destroyed.  Two-thirds  of  the  lower 
jaw  were  wanting.  The  right  half  of  the  middle  portion  of 
this  bone,  with  three  of  the  teeth,  was  found  adherent  to  a 
part  of  the  surface  of  the  right  ramus,  which  had  been 
fractured.  The  portion  supporting  the  coronoid  process  and 
the  condyle  was  considerably  depressed  backwards  to  meet 
the  other  fragments  of  this  bone ;  but,  as  they  were  not  in 
sufficiently  close  contact,  they  had  not  grown  to  each  other. 
All  the  edges  of  the  bones  broken  away  by  the  ball  had 
become  thinned  and  rounded,  forming,  with  the  correspond- 
ing soft  parts,  a  puckered,  irregular  border  surrounding  the 
gulf  in  the  middle  of  the  face.  To  perpetuate  the  history  of 
the  case.  Baron  H.  Larrey  has  had  the  preparation  of  the 
head  placed  in  the  museum  of  the  Hospital  of  Val  de  Grace." 

Fragments  of  shell  produce  as  frightful  injuries  as  round 
shot,  though  the  results  are  not  so  immediately  fatal. 
Professor  Longmore  recorded  {Lancet,  1855),  a  case  of 
injury  of  the  kind  occurring  under  his  notice  in  the  Crimea, 
in  which  the  right  half  of  the  palate  was  jammed  in,  and 
fixed  at  right  angles  to  the  other  half,  and  the  whole 
superior  maxilla  was  much  comminuted.  The  lower  jaw 
was  broken  in  three  places,  and  there  was  extensive 
laceration  of  the  soft  parts.  Great  difficulty  was  met  with, 
at  first,  in  unlocking  the  parts  of  the  palate  which  had  been 
driven  into  each  other,  and  when  they  were  separated  the 
right  half  hung  down  loosely  in  the  mouth.  The  parts  were 
carefully  restored  to  position,  and  the  patient  made  a  good 
recovery  without  deformity. 


INJURY    FEOM    SMALL    SHOT.  67 

A  charge  of  small  shot,  if  fired  near  enough  to  the  face  to 
do  more  than  lodge  in  the  skin  or  jaw-bone  (of  which  there 
is  a  good  example  in  the  Middlesex:  Hospital  Museum),  will 
produce  as  serious  injuries  to  the  jaws  as  a  bullet.  In  the 
Lancet  of  November  loth,  i860,  is  the  report  by  Mr. 
Swete,  of  Wrington,  of  a  case  of  very  severe  injury  to  the 
jaws  from  a  charge  of  "  dust-shot,"  fired  at  a  distance  of 
four  feet  from  the  patient,  a  boy  aged  nine  years.  The 
charge  entered  the  left  side  of  the  face,  and  passed  out  in 
front  of  the  right  ear,  carrying  away  with  it  the  greater  part 
of  the  lower  lip  and  jaw,  and  the  whole  of  the  chin.  Several 
pieces  of  bone  and  teeth  were  picked  up  in  an  adjoining 
field,  at  a  distance  of  ten  yards.  There  was  an  extensive 
ragged  wound  of  the  face,  extending  nearly  to  the  ear,  the 
right  half  of  the  upper  lip  being  destroyed,  and  the  teeth 
and  alveolus  of  the  same  side  carried  away.  The  lower  jaw 
was  shot  away  at  the  angle  on  the  right  side,  and  on  the 
left,  about  an  inch  of  the  body  of  the  jaw  and  one  molar 
tooth  remained.  Mr.  Swete  trimmed  the  ragged  edges  of 
the  jaw  and  brought  the  lacerated  parts  together,  and,  con- 
trary to  expectation,  the  patient  recovered  and,  by  means 
of  a  plastic  operation,  was  restored  to  a  condition  of  con- 
siderable comfort. 

Treatment. — Owing  to  the  enormous  improvement  that 
has  taken  place  in  the  healing  of  wounds  by  the  employ- 
ment of  antiseptics,  and  to  the  vast  strides  that  have  been 
made  in  prothetic  dentistry,  the  treatment  of  gunshot 
wounds  of  the  jaw  has  advanced  considerably  during  the  past 
twenty  years. 

It  is,  therefore,  of  great  interest  to  read  the  following- 
extract,  taken  from  the  official  "  Medical  and  Surgical 
History  of  the  British  Army  in  the  Crimea,"  vol.  ii,  p.  305, 
as  it  illustrates  the  experience  gained  in  that  war,  an 
experience  that  was  to  a  considerable  extent  confirmed  by 
that  of  the  later  American  war  : 

"  Wounds  of  the  face,  though  presenting  often  a  frightful 
amount  of  deformity,  are  not  generally  of  so  serious  a  nature 
as   their  first    appearance    might    lead    the    uninitiated   to 


as  GUXSHOT    INJURIES    OF    THE    JAWS. 

expect.  The  reason  of  tliis,  apart  from  the  fact  that  the 
face  contains  no  vital  organ,  seems  obviously  to  be  the  very 
free  supply  of  blood  which  this  part  receives.  From  this 
cause  the  Heshy  structures  readily  heal,  and  even  the  bones 
are  so  supplied  that  extensive  necrosis  rarely  happens.  The 
bone  tissues,  also,  are  softer  than  the  long  bones  of  the 
extremities,  and  we  therefore  but  seldom  here  meet  with 
long  fissures  and  extensive  necrosis  as  a  result  of  concussion 
of  bone,  so  often  seen  in  them.  This  leads  us  to  the  very 
important  practical  inference,  not  in  this  situation,  as  a  rule, 
to  remove  bony  fragments,  unless  the  comminution  be  great, 
or  the  fragment  completely  detached  from  the  soft  parts. 
Even  partially  detached  teeth  will  often  be  found  not  to 
have  lost  their  vitality  and,  if  carefully  readjusted,  will 
become  useful.  There  is  indeed  no  great  object  beyond, 
perhaps,  the  present  comfort  of  the  patient  to  be  attained 
in  removing  either  fragments  of  bone  or  loosened  teeth  in 
the  great  majority  of  instances.  If  they  die  they  become 
loose,  and  are  readily  lifted  away  without  trouble  to  the 
surgeon,  and  but  little  pain  to  the  patient.  This  observa- 
tion is  especially  applicable  to  fractures  of  the  lower  jaw. 
►Surgeons  in  this  war  have  seen  so  many  cases  of  badly- 
fractured  instances  of  this  kind  unite,  and  that  with  a  very 
small  amount  of  deformity,  that  men  of  experience  are  now 
excessively  chary  of  removing  any  portion  of  this  bone, 
unless  it  has  become  dead,  or  the  fragment  is  so  situated  as 
to  interfere  considerably  with  the  adjustment  of  the 
remainder,  or  the  bone  so  much  comminuted  as  to  give  no 
probable  hope  of  its  becoming  consolidated,  or  so  sharply 
angular  as  to  threaten  further  injury  to  the  soft  parts,  or  to 
interfere  materially  with  their  adjustment  and  retention  in 
situ.  In  these  fractures  of  the  lower  jaw,  much  less  support 
and  adjustment  than  we  are  in  the  habit  of  thinking 
advantageous  in  ordinary  cases  of  fracture  of  it,  will 
frequently  be  found  necessary,  or  even  admissible.  A  com- 
plicated apparatus  cannot  be  borne  at  first,  on  account  of 
the  condition  of  the  soft  parts,  and  the  application  of  slight 
support  by  a  gutta-percha  or  Startin's  wire  splint,  and  a 


TREATMENT  OF  LOOSE  FRAGMENTS.  69 

split  bandage,  is  all  that  can  be  done.  Any  attempt  at 
ligaturing  the  teeth  is  very  generally  not  only  useless,  but 
injurious,  and  it  is  surprising  how  the  parts  often  as  it  were 
adjust  themselves,  with  but  little  aid  from  the  surgeon. 
One  interesting  case  may  be  mentioned  where  the  whole  of 
the  bone,  from  angle  to  angle,  was  so  comminuted  by  gun- 
shot that  no  choice  was  left  but  to  remove  the  fragments. 
The  injury  to  the  soft  parts  was  very  considerable,  and  one 
difficulty,  occasioned  by  the  loss  of  all  support  in  front — 
viz.,  the  tendency  of  the  tongue  to  fall  backwards  and  close 
the  opening  of  the  glottis,  well  illustrated.  The  man, 
however,  generally  remedied  tins  himself  with  his  fingers, 
and  nothing  was  done,  or  required  to  be  done,  on  this 
account  beyond  carefully  watching  him.  He  naturally,  as 
it  were,  adopted  a  position  on  his  sidcj  resting  mainly  on 
his  forehead,  so  as  to  have  the  face  as  much  in  the  prone 
posture  as  possible,  and  thus  the  weight  of  the  organ 
assisted  in  keeping  it  in  position." 

The  strong  protest,  in  this  report,  against  the  extensive 
"  trimming  up  "  of  comminuted  fractures  of  the  jaws  was 
aimed  at  the  treatment  recommended  by  Dupuytren  and 
Baudens.  It  must  be  borne  in  mind,  however,  that  the 
advice  of  these  surgeons  in  recommending  the  removal  or 
rounding  off  of  all  fragments,  was  designed  to  prevent  as 
much  as  possible  the  profuse  and  oftensive  suppuration  that 
so  often  occurred  when  comminuted  pieces  of  bone  were  left 
in  the  wound.  At  the  present  day,  by  the  use  of  antisep- 
tics this  suppuration  can  be  much  diminished,  and  therefore 
the  radical  treatment  recommended  by  the  French  surgeons 
is  no  longer  necessary, 

In  the  treatment  of  gunshot  wounds  of  the  jaws  tliere 
are  three  essential  points  for  our  consideration : 

I.  The  Treatment  of  Loose  Frarjments. — In  cases  where 
the  fragments  are  quite  separated  from  the  jaw  and  are 
small  in  size  it  is  better  to  remove  them,  but  if  the  frag- 
ment be  a  large  one,  bearing  as  it  often  does  one  or  more 
teeth,  efforts  should  be  made  to  preserve  it  by  fixing  it  to 
the  rest  of  the  jaw,  although  the  fragment  may  be  com- 


70  GUNSHOT  INJURIES    OF   THE   JAWS. 

pletely  separated.  Where  the  fragments  are  united  to  the 
jaw  or  soft  parts  by  shreds  of  tissue  they  should  be  preserved. 
The  fractured  surfaces  of  the  jaw  should  not  be  rounded  off, 
unless  a  very  sharp  spicule  of  bone  is  injuriously  pressing 
into  the  soft  parts. 

2 .  The  Fixation  of  tlie  Seat  of  Fracture  is  usually  a  very 
simple  matter  if  the  fracture  is  not  comminuted.  A  four- 
tailed  bandage  or  a  simple  jaw  splint  generally  answers 
admirably. 

.  In  cases  of  extensive  fracture  with  comminution,  the 
fixation  may  be  a  very  difficult  matter.  Any  complicated 
method,  such  as  Hammond's  wire  splint,  or  the  treatment 
recommended  by  Dr.  Angle  (see  chap.  iii.  p.  35),  is  out  of 
the  question  in  the  conditions  under  which  military  surgery 
is  carried  out.  Probably  the  best  method,  under  such 
circumstances,  is  a  rapidly  improvised  gutta  percha  splint 
as  recommended  by  Hamilton. 

The  application  of  a  ligature  of  silk  or  wire  to  sound 
teeth  on  either  side  of  the  fracture  may  be  advisable  in 
some  cases,  but  unless  great  care  be  taken  the  teeth  may 
become  loose,  and  undue  mobility  between  the  fragments 
ensue.  When  this  method  is  employed,  an  external  gutta- 
percha splint  should  be  used  also. 

In  many  cases  the  injury  to  the  soft  parts  may  compli- 
cate the  treatment  very  much  and  no  definite  rules  can  be 
laid  down.  The  successful  treatment  of  such  cases  depends 
upon  the  ingenuity  and  care  bestowed  upon  them  by  the 
surgeon  in  charge. 

3.  Tlie  after-treatment  of  the  case  is  concerned  with  the 
healing  of  the  wound  and  the  feeding  of  the  patient.  The 
wound  must  be  irrigated  or  syringed  out  frequently  during 
the  day  with  antiseptic  lotions,  such  as  carbolic  acid,  per- 
manganate of  potassium,  boracic  acid,  &c.,  and  should  be 
dusted  over  with  a  powder,  a  very  useful  one  being  a 
mixture  of  iodoform,  creolin,  and  boracic  acid  in  equal  parts. 
The  patient  must  be  fed  with  liquid  food,  introduced,  if 
necessary,  into  the  pharynx  by  a  tube. 

The    after-results   of    gunshot  wounds  of   the  jaws  are 


AFTEK-TKEATMEXT.  7l 

often  very  unsatisfactory.  The  great  deformity  produced 
by  the  contraction  of  the  cicatricial  tissue  is  very  difficuh 
to  prevent,  and  it  is  only  of  recent  years  that  attempts  to 
obtain  a  better  result  have  been  followed  by  success. 

For  the  advance  of  the  knowledge  in  this  direction  we 
are  chietly  indebted  to  MM.  Preterre  and  Claude  Martin. 
The  principle  adopted  by  these  dentists  is  to  insert  a  me- 
chanical contrivance  into  the  mouth  as  soon  as  possible 
after  the  infliction  of  the  wound,  in  order  to  prevent  the 
cicatricial  tissue  pulling  the  remaining  portions  of  the  jaw 
out  of  their  place  during  the  processes  of  healing.  When 
the  wound  is  sufficiently  healed  a  suitable  plate,  bearing 
teeth  if  necessary,  is  fitted  to  the  mouth.  We  thus  see 
that  the  mechanical  treatment  is  divided  into  two  stages  : 
immediate  or  temporary  prothesis,  and  secondary  or  perma- 
nent prothesis.  This  method  has  not  received  a  sufficient 
trial  in  this  country  for  us  to  come  to  any  definite  conclu- 
sion, but  it  has  been  employed  in  France,  apparently  with 
excellent  results.  {Dc  la  Prothese  Immediate  applique  a  la 
resection  dcs  Maxillaircs,  par  Claude  Martin.  Paris  :  Masson, 
1889  ;  Traite  dc  Chirurgie  de  Guerre,  par  Delorme,  vol.  ii. 
Paris  :  Bailliere,  1893.) 


CHAPTER    VI. 

DISLOCATION    OF    THE    LOWER   JAW. 

Dislocation  of  the  lower  jaw  may  be  unilateral  or  bilateral, 
the  latter  being  the  more  frequent  variety,  since  of  2  8  cases 
of  dislocation  given  by  Giraldes,  1 5  were  of  both  condyles  ; 
and  of  76  cases  given  by  Malgaigne,  54  were  the  same,  31 
of  these  last  being  in  women.  Bilateral  dislocation  occurs 
most  frequently  in  middle  age,  though  it  is  not  unknown  in 
youth  and  old  age ;  thus  Sir  Astley  Cooper  gives  the  case  of 
a  child,  who  experienced  the  accident  from  forcing  an  apple 
into  his  mouth,  and  both  Nelaton  and  Malgaigne  have  met 
with  it  in  old  people  of  sixty-eight  and  seventy-two  years 
of  age.  The  possibility  of  dislocation  of  the  jaw  following 
traction  on  the  chin  with  the  finger  or  hook  in  delivery 
need  be  only  alluded  to,  since  the  occurrence  must  be 
unknown,  or  nearly  so,  in  the  case  of  living  children.  The 
less  frequent  occurrence  of  the  accident  in  the  extremes  of 
age  may  be  explained,  partly  hj  the  smaller  liability  of 
children  and  old  people  to  external  violence,  and  also  by  the 
fact  that,  owins  to  the  obtuseness  of  the  ansfle  formed 
between  the  ramus  and  the  body  of  the  bone  at  those  ages, 
the  leverage  of  the  jaw  is  diminished,  and  the  muscles  do 
not  act  in  such  vertical  lines  as  in  middle  age.  The  expla- 
nation offered  by  M.  Nelaton  —  viz.,  that  in  youth  the 
coronoid  processes  are  too  short,  and  in  old  age  directed  too 
far  back,  to  impinge  upon  the  malar  process  of  the  upper 
jaw — appears  to  be  untenable,  and  will  be  referred  to  in 
describing  the  pathology  of  dislocation. 

Etiology. — In  the  majority  of  cases  the  immediate  cause 
has  been  muscular  action  alone.     By  no  means  infrequent 


PATHOLOGY    OF    DISLOCATION.  /  ■> 

causes  are  yawning,  vomiting,  or  shouting,  in  all  of  which 
actions  the  patient's  mouth  is  opened  to  its  fullest  extent ; 
or  it  may  result  from  blows  or  the  kicks  of  animals,  and  this 
is  particularly  the  case  with  the  unilateral  form  of  the 
affection.  Causes  acting  within  the  mouth  may  also  pro- 
duce dislocation — e.g.,  the  introduction  of  an  apple,  as  in 
Sir  Astley  Cooper's  case,  already  alluded  to,  or  the  intro- 
duction of  the  stomach-pump.  Extraction  of  teeth,  even 
in  the  most  skilful  hands,  has  been  known  to  produce  the 
accident,  which  has  also  been  caused  by  the  ordinary  dental 
operation  of  taking  a  model  of  the  lower  jaw.  (Salter, 
British  Journal  of  Dental  Science,  July,  1 87 1.)  Dr.  Guignier, 
of  Montpelier,  has  also  reported  (Abstract  of  Medical  Sciences, 
vol.  ii,  1866)  an  example  of  complete  dislocation  occurring 
during  the  laryngoscopic  examination  of  a  lady,  aged  thirty- 
eight,  in  whom  reduction  was  readily  effected. 

Patlwlogy. — The  ]3athology  of  dislocation  of  the  jaw  has 
been  a  subject  of  considerable  discussion  and  investigation 
from  the  earliest  days  of  surgery  to  the  present  time, 
and  various  views  respecting  it  have  been  brought  forward 
by  different  authorities.  When  the  mouth  is  opened  to  its 
fullest  extent,  each  condyle  of  the  jaw  leaves  the  true  glenoid 
cavity  and  rests  against  the  articular  eminence  and  the 
inter-articular  fibro-cartilage,  which  is  drawn  forward  by  the 
pterygoideus  externus,  the  same  muscle  which  advances  the 
jaw  itself.  The  articular  eminence  is  covered  by  articular 
cartilage  and  by  the  synovial  membrane  reflected  between 
it  and  the  cartilage,  and  a  second  synovial  membrane  being 
placed  between  the  cartilage  and  the  condyle  of  the  jaw, 
the  necessary  freedom  of  movement  is  insured.  A  cavity  is 
thus  left  immediately  behind  the  condyle,  which  can  be 
readily  felt  in  the  healthy  living  subject,  and  which  is  only 
exagjo-erated  in  cases  of  dislocation.  This  forward  movement 
of  the  condyle  has  been  proved  experimentally  by  C.  E. 
Luce  (Boston  Medical  and  Surgical  Journcd,  1889),  who  has 
shown  that  the  condyle  may  reach  the  summit  of  the 
eminentia  articularis,  or  even  get  in  front  of  it.  This  is 
contrary    to    the    teachings     of   Morris,    Humpln^ey,    and 


74 


DISLOCATION    OF    THE    LOWER    JAW. 


others,  who  state  that  the  condyle  never  quite  reaches  the 
summit. 

When  tlie  jaw  is  in  this  position,  but  a  very  slight  force  is 
needed  to  carry  the  condyle  over  the  articular  eminence  and 
produce  a  dislocation,  and  this  is  brought  about,  either  by  a 
force  applied  to  the  chin,  when,  owing  to  the  length  of  the 
lever,  the  result  is  readily  induced ;  or  by  a  spasmodic  con- 
traction of  the  external  pterygoid  muscles,  which,  as  has 
been  stated,  are  already  in  action.  The  lateral  ligaments 
of  the  joints  have  no  power  to  check  this,  and  the  few  fibres 

Fig.  35. 


which  surround  the  synovial  membrane  and  form  a  loose 
capsule  are  easily  stretched,  but  never  tear.  The  accom- 
panying illustration  (Fig.  35)  from  Sir  Astley  Cooper's  work 
on  "  Dislocations,"  shows  the  position  of  the  bone  at  this 
period,  but  is  wanting  in  the  ligaments  and  inter-articular 
cartilage,  which  latter  is  ordinarily  carried  forward  with  the 
condyle.  Immediately  that  the  condyles  are  dislocated  the 
masseter  and  internal  pterygoid  muscles  contract,  and  draw 
the  jaw  forwards  and  upwards  so  as  to  produce  the  projection 
of  the  chin  characteristic  of  the  accident.  This  last  muscular 
action  was  originally  described  by  Petit,  and  has  been 
denied ;  but  has  recently  been  confirmed  by  Heinlezn  and 
Busch,  who  found  experimentally  on  the  dead  body,  that  by 
replacing  the  muscles  by  india-rubber  bands  acting  in  the 
same   direction   as  the  muscles,  the  luxation  could  be   in- 


PATHOLOGY    OF    DISLOCATION.  75 

variably  maintained  and  the  characteristic  deformity  pro- 
duced. 

Both  Maisonneuve  {L' Union  Medical r^  1863)  and  Otto 
Weber  {op.  cif.),  have  experimented  upon  the  dead  body,  and 
liave  succeeded  in  producing  dislocation  of  the  jaw  by 
imitating  the  three  movements  already  described,  when  the 
following  is  the  condition  of  the  parts  found  upon  dissec- 
tion :  The  condyles  are  in  front  of  the  root  of  the  zygoma, 
the  coronoid  processes  are  completely  surrounded  by  the 
tendons  of  the  temporal  muscles,  and  are  quite  below-  and 
scarcely  ever  touch  the  malar  bone.  The  capsular  ligament 
is  tense,  but  not  ruptured ;  the  external  lateral  ligament  is 
tense,  and  passes  from  behind  forwards  instead  of  from  be- 
fore backwards  ;  tlie  internal  lateral  and  stylo-maxillary 
ligaments  are  stretched,  and  this  is  increased  by  raising  the 
chin.  The  inter-articular  fibro-cartilages  are  attached  to  and 
follow  the  motions  of  the  condyles.  According  to  Maison- 
neuve, the  temporal  muscles  are  only  stretched  ;  but  Weber 
says  that  some  of  the  fibres  are  usually  torn  off  the  coronoid 
process. 

Nearly  all  observers  have  obtained  results  similar  to 
those  obtained  by  Maisonneuve.  Eecently,  however,  some 
researches  of  ISTelaton  have  been  published  for  the  first  time, 
and  he  came  to  the  conclusion  that,  in  the  great  majority 
of  cases,  the  capsule  was  torn.  "  La  syuoviale  est  decliii-ee 
en  avant  et  au  clessous  du  menisque  dans  la  tres  grande 
majorite  des  cas,  bien  qu'on  I'ait  rencontree  intacte  dans  deux 
autopsies  "  (Traite  de  Chirurgic,  Duplay  et  Eeclus).  On  the 
other  hand,  Dr.  Julius  Snitzler  has  quite  recently  produced 
the  dislocation  on  the  dead  body,  and  in  no  case  did  he 
find  any  tearing  of  the   capsule  {Centralblatt  filr  Chirurgie, 

1891). 

The  fixation  of  the  dislocated  jaw  has  received  a  different 
explanation,  and  has  been  attributed  to  the  catching  of  the 
coronoid  process  against  the  malar  bone,  or  the  malar 
process  of  the  superior  maxilla.  This  view  was  originally 
maintained  by  Fabricius  ab  Aquapendente,  by  Monro, 
and  more  recently  by  ISTc'laton   (Bevvc  MMico-CMrurgicak, 


76 


DISLOCATION    OF    THE    LOWER  JAW. 


torn,  vi),  wlio  is  followed  by  Malgaigne  in  his  treatise  on 
"Dislocations"  (1855).  Nelaton  maintains  that  in  his 
experiments  on  the  dead  body  he  constantly  found  the 
coronoid  process  fixed  against  the  malar  bone  ;  and  he 
appeals  also  to  a  unique  preparation  of  a  pathological  dis- 
location, which  he  dissected  and  presented  to  the  Musee 
Dupuytren.  The  accompanying  illustration  (Fig.  36), 
reduced  from  Malgaigne's  Atlas,  is  from  the  preparation  in 
question.     The  coronoid  process  in   this   certainly  touches 

Fig.  36. 


the  malar    bone,   and    the  relations   of    the  inter-articular 
cartilage  and  external  lateral  ligaments  are  well  seen. 

Eibes  and  Monteggia  agree  with  Maisonneuve  and  Weber 
in  believing  that  in  most  jaws  the  coronoid  process  is  not 
long  enough  to  reach  the  malar  bone ;  and  the  last-named 
author  mentions  that  Eoser  was  unable  to  reduce  an  old 
dislocation  of  eight  weeks'  standing,  even  after  cutting 
through  both  coronoid  processes  from  within  the  mouth  by 
means  of  bone  forceps.  From  experiments  I  have  myself 
instituted,  I  believe  the  view  of  Maisonneuve  and  Weber  to 
be  correct- — viz.,  that  the  coronoid  process  does  not  become 
fixed  acjainst  the  malar  bone.     In  the  macerated  skull  it  is 


SY.M1T03LS    OF    DISLOCATION. 


7r 


easy  to  dislocate  the  condyle  so  far  in  front  of  the  articular 
eminence  as  to  cause  the  coronoid  process  to  be  hooked 
against  the  malar  Lone ;  but  this  is  by  no  means  easy  on  the 
subject,  even  when  the  parts  are  dissected,  and  can  only  be 
accomplished  by  tearing-  the  structures  of  the  joint  very 
considerably.  Besides,  the  position  the  jaw  assumes  when 
the  condyles  are  so  driven  forward,  is  not  that  of  the 
oi'dinary  form  of  d|slocation,  the  jaws  being  too  widely 
separated,    and    the  "^itCiJrawn    back    instead    of    beine" 

J  FTr;. 


advanced.  Were  the  coronoid  processes  fixed  against  the 
malar  bones,  it  would  be  impracticable  to  effect  a  reduction 
by  elevating  the  chin,  as  is  frequently  done ;  and,  moreover, 
the  gradual  improvement  noticed  in  old-standing  cases  of 
dislocation  would  be  impossible. 

A  preparation,  illustrating  the  anatomy  of  dislocation, 
was  dissected  for  me  by  my  friend  the  late  Mr.  Marcus 
Beck,  and  from  one  side  of  it  the  drawing  (Fig.  2i7)  was 
made. 

Symptoms  of  Dislocation. — When  the  dislocation  is  bilateral, 
the  deformity  is  so  evident  as  at  once  to  attract  attention. 
The  mouth  is  open  and  the  jaw  fixed,  with  the  lower  teeth 


78 


DISLOCATION    OF    THE    LOWER    JAW. 


carried  beyond  those  of  the  upper  jaw,  as  seen  in  Fig.  38, 
from  Fergusson.  Speech  and  deglutition  are  much  inter- 
fered with,  since  the  lips  cannot  be  approximated ;  and,  for 
the  same  reason,  the  saliva  dribbles  from  the  mouth.  On 
examining  the  neighbourhood  of  the  temporo-maxillary 
joint,  a  distinct  and  unusual  hollow  will  be  seen  immediately 
in  front  of  the  ear,  and  the  condyle  may  be  both  seen 
and  felt  in  front  of  this.  The  coronoid  process  forms  a 
projection  immediately  behind  and  below  the  malar  bone, 


and  may  be  readily  felt  in  its  abnormal  position  from  the 
mouth.  The  masseter  is  firmly  contracted  and  strongly 
prominent.  E.  W.  Smith,  in  his  work  on  "  Fractures  and 
Dislocations,"  has  also  specially  called  attention  to  a  promi- 
nence immediately  above  the  zygoma,  which  has  not  been 
usually  described,  and  which  he  believes  is  due  to  the 
condyle  pressing  forward  and  stretching  the  posterior  fibres 
of  the  temporal  muscle,  but  which  I  believe  to  be  caused  by 
their  spasmodic  contraction.  The  accompanying  drawing 
(Fig.  39),  taken,  by  permission,  from  the  work  referred  to, 
illustrates  both  these  points. 


SYMPTOMS    OF    DISLOCATION. 


79 


In  dislocation  of  only  one  condyle  the  signs  are  less  mani- 
fest, and  may  possibly  be  overlooked  or  misinterpreted.  The 
chin  is  visually  directed  towards  the  sound  side  instead  of 
toward  the  injured  side,  as  is  the  case  in  fracture  of  the  neck 
of  the  bone ;  the  hollow  in  front  of  the  ear  is  equally  visible 
in  this  as  in  the  double  form  of  dislocation,  and  speech  and 
deglutition  are  similarly  to  some  degree  interfered  with.  The 
obviousness  of    the  direction  of  the  chin  to  one   side  will 

Fig.  39. 


depend  in  some  degree  upon  the  original  prominence  of  that 
feature  in  the  individual,  and  too  much  stress  must  not  be 
laid  upon  the  symptom  :  thus  Hey,  in  his  "  Practical  Obser- 
vations in  Surgery  "  ( 1 8  1 4),  remarks  :  "  One  would  expect, 
from  a  consideration  of  the  structure  of  the  parts,  and  from 
the  description  given  in  systems  of  surgery,  that  the  chin 
should  be  evidently  turned  towards  the  opposite  side ;  but  I 
have  repeatedly  seen  the  disease  (accident)  where  I  could 
discern  no  alteration  in  the  position  of  the  chin.  The 
symptom  which  I  have  found  to  be  the  best  guide  in  this 


80  DISLOCATION    OF    THE  LOWER    JAW. 

case,  is  a  small  lioUovv  which  may  be  felt  behind  the  condyle 
that  is  dislocated,  which  does  not  subsist  on  the  sound  side." 
K.  W.  Smith  also  mentions  that,  in  a  case  of  luxation  of  the 
right  condyle,  he  had  seen  the  efforts  at  reduction  applied  to 
the  left  side. 

Old-standiwj  Dislocations. — From  various  causes  disloca- 
tions of  the  jaw  have  been  from  time  to  time  overlooked, 
and  have  not  been  brought  under  the  notice  of  the  surgeon 
for  weeks  or  even  months  after  the  accident.  Thus  R.  W. 
Smith  (o-p.  cit.)  narrates  the  case  of  a  woman  who  dislocated 
her  jaw  in  an  epileptic  fit,  whilst  an  inmate  of  one  of  the 
Dublin  Hospitals,  but,  the  accident  escaping  notice,  the  bone 
remained  unreduced.  The  drawing  in  Mr.  Smithes  work 
represents  the  condition  of  the  patient  one  year  after  the 
accident,  and  it  is  to  be  remarked  that  though  the  signs 
of  dislocation  are  sufficiently  obvious  in  the  hollow  in  front 
of  the  ear  and  the  projection  of  the  chin,  yet  that  the  patient 
was  able  to  close  the  lips  so  as  to  retain  the  saliva  and 
speak  intelligibly,  but  was  able  to  open  the  mouth  only  to 
a  limited  extent.  Indeed  in  these  cases  of  unreduced  dis- 
location there  seems  to  be  no  great  inconvenience  from  the 
displacement. 

Mr.  John  Couper  has  recorded  an  equally  interesting 
case  in  the  London  Hospitcd  Reports,  vol.  i,  p.  262.  More 
than  three  months  before,  the  patient  had  dislocated  her 
jaw  bilaterally  (for  the  second  time)  whilst  yawning,  and 
when  seen  she  presented  the  appearance  shown  in  the 
illustration  (Fig.  40),  for  which  I  am  indebted  to  the  editors 
of  the  Reports.  Mr.  Couper  found  that  the  jaw  had  re- 
covered a  certain  amount  of  mobility,  so  that  the  incisors 
of  the  two  jaws  could  be  approximated  to  within  an  inch, 
and  separated  for  an  inch  and  a  half,  the  molar  teeth  being 
nearly  in  contact  during  extreme  closure.  The  chin  was 
depressed  and  carried  forward,  and  the  hollow  in  front  of 
the  ear  was  well  marked.  The  patient's  utterance  was 
slightly,  if  at  all,  impaired,  and  the  labial  consonants  were 
pronounced  as  distinctly  as  other  sounds,  and  the  saliva  was 
retained.       Mr.  Couper   made    attempts,  under  chloroform, 


OLD    DISLOCATIONS.  81 

both  with  levers  and  forceps,  to  reduce  the  dislocation 
but  without  success,  but  the  efiect  of  the  operation  was  to 
increase  the  range  of  motion  of  the  jaw. 

A  second  case  of  old  double  dislocation  of  the  jaw  oc- 
curred in  the  London  Hospital  in  the  year  following  Mr. 
Couper's,  and,  being  of  only  two  months'  standing,  was  re- 
duced  with   some   little  difficulty  by  Mr.  Hutchinson,  who 

Fto.  4c. 


says  {London  Hospital  Bcports,  vol.  ii,  p.  ^'^)  :  "The  woman 
was  unable  to  shut  her  mouth,  and  her  chin  stuck  forward, 
giving  her  face  an  awkward,  lantern-jawed  expression  ;  but 
there  was  no  wide  gaping  and  she  could  easily  shut  her  lips," 
The  readiness  with  which  tlie  accident  may  be  overlooked 
is  illustrated  by  the  concluding  observation  of  Mr.  Hutchin- 
son :  "  We  had  fancied  at  first  that  there  was  but  little 
facial  deformity,  but  this  impression  was  corrected  at  once 
when  we  had  her  natural  expression  before  us  by  way  of 
contrast." . 


82  DISLOCATION   OF    THE    LOWER   JAW. 

Brockway  reported  an  interesting  case  of  unreduced  bi- 
lateral dislocation  of  thirteen  months'  duration.  Under 
ether  unsuccessful  attempts  at  reduction  were  made.  An 
incision  was  then  made  over  each  joint  and  the  condyles 
were  replaced.  The  mouth  was  kept  closed  for  seven  days, 
and  the  patient  was  discharged  on  the  tenth  day  with  good 
movement. 

Probably  the  longest  period  which  has  elapsed  after  the 
accident  and  has  been  followed  by  successful  reduction,  is 
ten  months,  and  this  occurred  in  a  man  in  whom  Mr.  McArdle 
reduced  the  dislocation  (Med.  Press  and  Circular,  London, 
1885). 

Other  examples  of  the  successful  reduction  of  old- standing 
dislocations  have  been  from  time  to  time  recorded.  Thus, 
Mr.  Pollock  successfully  reduced  a  dislocation  of  four 
months'  duration  in  a  woman,  by  inserting  wedges  between 
the  molar  teeth  and  drawing  up  the  chin  by  means  of  a 
strap  tourniquet  passed  over  the  head  (Si.  Georges  Hospital 
Meports,  vol.  i).  A  slightly  longer  period  than  this  elapsed 
in  Mr.  Golding  Bird's  case  (see  p.  87). 

Sir  Astley  Cooper  ("  Fractures  and  Dislocations  ")  gives 
a  case  in  which  Mr.  Morley  reduced  a  dislocation  after  a 
month  and  five  days.  Stromeyer  had  a  similar  case.  Spat 
was  successful  in  a  case  fifty-eight  days  old ;  Demarquay  in 
one  of  eighty- three  days  (Weber,  op.  cit.) ;  and  Donovan  in 
one  of  even  ninety-eight  days  (Dublin  Medical  Press,  May, 
1842). 

Pare  Forms  of  Dislocation. — A  few  cases  of  rare  forms  of 
dislocation  with  fracture  have  been  described.  The  cases 
recorded  by  Eobert  of  dislocation  outwards  with  fracture  on 
the  opposite  side,  and  by  Mr.  Croker  King  and  Mr.  Gunning 
of  New  York,  of  dislocation  outwards  and  backwards  with 
fracture  of  the  symphysis,  have  been  already  referred  to 
under  the  head  of  "  fracture  complicated  by  dislocation."  It 
might  be  supposed  from  the  anatomy  of  the  parts  that  dis- 
location backwards  would  be  impossible  without  fracture  of 
the  front  wall  of  the  meatus  auditorius  externus  or  of  the 
glenoid  cavity,  and  the   specimen  in  St.  George's   Museum 


CONGENITAL    DISLOCATIONS.  83 

is  an  instance  in  point.  In  Mr.  King's  case  there  can 
be  little  doubt  that  there  was  some  injury  to  the  meatus, 
ifrom  the  haemorrhage  which  occurred. 

M.  Baudrimont  has  reported  a  case  of  dislocation  of  both 
condyles  backwards,  in  which  the  anterior  inferior  wall  of 
the  auditory  meatus  on  each  side  was  fractured,  and  the 
auditory  passage  was  almost  completely  obliterated  by  the 
projection  of  the  condyle  into  it  (BuUctiii  et  Mem.  Soc.  de 
Cliirurg.  dc  Paris,  1882). 

From  cases  reported  by  Coe  {American  Medical  Journal, 
1889)  and  Thiene  (i?er/,  Klinisclic  WocJicnschrift,  1888)  it 
seems  that  this  dislocation  can  take  place  without  any  in- 
jury to  the  auditory  meatus.  The  condyle  may  slip  into  a 
temporary  receptacle  bounded  in  front  by  the  tjmipanic 
tubercle,  behind  by  the  mastoid  process,  and  internally  by 
the  styloid  process  {fosse  tympanico-stylo-mastoidiennc).  In 
the  young  and  old,  owing  to  the  alteration  in  the  maxillary 
angle,  the  masseter  and  internal  pterygoid  muscles  become 
solely  elevators,  losing  their  forward  action. 

All  the  cases  recorded  by  these  observers  occurred  in 
women,  generally  at  the  end  of  the  act  of  gaping. 

Congenital  Dislocations. — Cases  of  congenital  dislocation 
of  the  lower  jaw,  with  more  or  less  malformation,  have  been 
•recorded  by  Guerin  {Gazette  Medicate  de  Paris,  1841)  and 
K.  W.  Smith  ("  On  Fractures  in  the  Vicinity  of  Joints"),  who 
gives  elaborate  drawings  of  the  dissections  of  the  case. 
Mention  may  be  made  also  of  the  cases  of  congenital  small- 
aiess  and  arrest  of  development  recorded  respectively  by 
Langenbeck  {Archiv  filr  Klin.  Chir.,  Bd.  i),  by  Mr.  Canton 
{Pathological  Society's  Transactions,  vol.  xii),  and  Dr. 
Ogston's  elaborate  paper  on  "  Congenital  Malformation  of 
the  Lower  Jaw"  {Glasgoio  Medical  Journcd,  1875);  but 
these  subjects  do  not  properly  come  within  the  scope  of 
this  work. 

Sid)-luxation  of  the  jaw  was  first  described  by  Sir  Astley 
Cooper,  and  has  been  generally  recognised  by  surgical  writers 
since  his  time.  It  will  be  described  in  the  chapter  on 
.diseases  of  the  temporo-maxillary  joint. 


8i  DISLOCATION    OF    THE    LOWEE    JAW. 

Recurring  Dislocation. — Cases  are  occasionally  met  with 
in  wliicli  there  is  a  great  tendency  for  the  dislocation  to 
recur,  it  may  be  several  times  during  a  year.  Such  a  case 
will  he  mentioned  when  the  treatment  of  dislocation  is 
dealt  with. 

Dislocation  of  Inter-articvlcir  Fihro-cartilage, — Henry  Lee, 
in  the  Lancet,  1890,  describes  a  case  of  this  kind.  There 
was  dribbling  of  saliva  and  enlargement  of  the  left  sub- 
maxillary  gland.  This  condition  of  the  gland  was  con- 
sidered by  Lee  to  be  due  to  injury  of  the  chorda  tympani 
nerve. 

Treatment  of  Dislocation. — Although  ordinarily  requiring 
the  assistance  of  the  surgeon,  dislocations  of  the  jaw  have 
been  known  to  become  reduced  spontaneously,  or  with  the 
aid  of  the  patient  alone.  Nelaton  mentions  a  case  of  spon- 
taneous reduction  occurring  in  his  own  practice ;  and  Sir 
Astley  Cooper  narrates  the  case  of  a  lady  who  reduced  a 
dislocation  of  one  side,  induced  by  sea-sickness,  with  the  help 
of  an  oyster-knife.  Levison  also  gives  the  case  of  an  old 
man  who,  suffering  from  recurring  dislocation,  especially 
when  waking  from  sleep,  "  would  pull  his  jaw  and  press  it 
backwards,  when,  after  about  half  an  hour's  work,  bang  it 
seemed  to  go,  and  all  was  right  again." 

In  recent  cases  of  dislocation,  reduction  may  usually  be 
accomplished  with  facility  by  various  methods  of  manipula- 
tion, but  cases  of  long  standing  may  require  some  instru- 
mental assistance.  The  simplest  mode  is  for  the  head  of 
the  patient  to  be  held  firmly  against  the  breast  of  an 
assistant,  while  the  operator,  having  protected  his  thumbs 
with  lint  or  a  towel  twisted  round  them,  presses  them  as  far 
back  as  possible  upon  the  molar  teeth,  grasping  the  jaw  at 
the  same  time  with  his  fingers.  Pressure  is  then  made 
downwards  and  backwards,  so  as  to  free  the  condyles  from 
the  articular  eminence,  and  as  soon  as  this  is  done  the  chin 
is  elevated  and  the  condyles  sKp  into  place.  This  plan  may 
be  advantageously  modified  by  reducing  the  condyles  suc- 
cessively though  at  the  same  operation,  care  being  taken 
that  the  condyle  first  reduced  is  not  again  dislocated,  as  has 


TREATMENT    OF    DISLOCATION.  85 

happened  more  than  once.  The  proceeding  is  thus  ren- 
dered easier,  because  one  condyle  forms  a  point  of  support 
or  fulcrum  for  the  other,  so  tliat  the  entire  jaw  is  used  as  a 
lever,  instead  of  the  thumbs  forming  the  fulcra,  as  in  the 
other  method.  This  latter  method  also  obviates  the  danger 
of  the  jaw  suddenly  closing  upon  the  thumbs,  though  this 
is  probably  somewhat  exaggerated. 

Hamilton  considers  that  the  method  described  by  Hippo- 
crates might  often  be  tried  with  advantage.  By  this 
method  the  chin  is  greatly  depressed,  and  then  pressed 
backwards  in  the  direction  of  the  articulation. 

Sir  Astley  Cooper  recommended  the  introduction  of  two 
corks  (or  one  in  the  case  of  single  dislocation)  iDctween  the 
molar  teeth  to  act  as  fulcra,  the  chin  being  then  drawn 
upwards ;  and  narrates  the  case  of  a  madman,  where,  for  his 
own  safety,  he  used  two  table-forks  with  a  handkerchief 
wrapped  round  them  to  act  as  fulcra.  The  same  method 
was  originally  employed  by  Ambrose  Pare,  who  used  wedges 
of  wood  instead  of  cork,  and  his  example  has  been  followed 
by  numerous  surgeons.  Mr.  Pollock  employed  this  method 
successfully  in  1866,  in  a  case  of  dislocation  of  four  months' 
standing ;  a  gag  being  placed  between  the  molar  teeth,  and 
the  strap  of  an  ordinary  tourniquet  being  applied  round  the 
head  and  beneath  the  jaw,  so  that  the  screw  might  exert  its 
power  upon  the  dislocated  bone  (^S'^.  George's  Hospital 
Meports,  vol.  i). 

Instead  of  mere  fulcra  having  been  inserted  between  the 
molar  teeth,  levers  have  been  employed  to  depress  the  lower 
jaw  in  cases  of  difficulty ;  thus.  Sir  Astley  Cooper  narrates 
that  Mr.  Fox,  the  dentist,  "  placed  a  piece  of  wood  a  foot 
long  upon  the  molar  tooth  of  one  side,  and  raising  it  at  the 
part  at  which  he  held  it,  depressed  the  point  at  the  jaw  on 
that  side,  and  succeeded  in  reducing  the  condyle.  He  then 
did  the  same  on  the  other  side,  and  thus  replaced  the  bone." 
Here,  of  course,  the  upper  jaw  formed  the  fulcrum,  and  the 
advantage  of  acting  upon  one  condyle  at  a  time  is  seen. 
This  method  is  not  invariably  successful,  however,  for  in  the 
case  of  old  dislocation  under  Mr.   Gouper's    care,   already 


86  DISLOCATION    OF    THE    LOWEE    JAW. 

related,  tliat  gentleman  employed  levers  of  pine  wood  six 
inches  lon^  witliout  success. 

A  more  powerful  leverage  action  is  obtained  by  th& 
forceps  invented  by  Stromeyer,  which  is  shown  in  the- 
illustration  (Fig.  41).  The  forceps  consists  of  two  blades 
expanded  at  the  extremities,  so  as  to  fit  pretty  accurately  the 
dental  arches  of  the  upper  and  lower  jaws,  and  covered  with 
leather.  A  spring  between  the  handles  tends  to  keep  the 
blades  closed,  and  a  screw  and  nut,  acting  upon  the  handles, 
is  able  to  close  them  so  as  to  make  the  blades  diverge- 
forcibly  ;  at  the  same  time  a  movable  pin  loosens  this,  so 
that  the  blades  may  be  closed  again  the  moment  they  have 
done  their  work.  Tlie  blades  being  closed,  and  introduced 
between  the  teeth  as  far  as  possible,  are  then  separated  by 

Fig.  41. 


means  of  the  nut  and  screw,  until  the  condyles  are  dis- 
entangled from  the  articular  eminences,  when,  being  suddenly 
closed,  they  are  withdrawn,  an  assistant  at  the  same  time- 
pressing  the  jaw  backwards,  so  as  to  bring  the  condyles  into 
the  glenoid  cavities.  In  this  way  Stromeyer  reduced  a 
dislocation  of  thirty-five  days'  standing. 

Nelaton,  whose  view  with  regard  to  the  locking  of  the 
coronoid  processes  against  the  malar  bones  has  been  already 
referred  to,  advocates  acting  directly  upon  these  processes, 
in  order  to  force  them  and  the  condyles  backwards.  The 
surgeon  may  stand  in  front  of  the  patient,  and,  with  his- 
thumbs  pressing  against  the  coronoid  processes,  within  or 
without  the  mouth,  may  grasp  the  mastoid  processes  with  his 
fingers,  and  thus  have  a  firm  ]joint  d'appid  to  act  from ;  or,. 
sitting  behind  the  patient,  he  may  place  his  thumbs  on  the- 
nape  of  the  neck,  and  endeavour  to  draw  the  jaw  backwards 
with  his  fingers. 

Maisonneuve,  though  differing  from   Xelaton  with  regardi 


METHODS    OF    KEDUCTION.  87 

to  the  pathology  of  the  affection,  agrees  with  him  in  the 
propriety  of  acting  upon  the  coronoid  processes.  The 
following  were  the  conclusions  he  arrived  at  from  numerous 
experiments  on  the  dead  body : — Blows  on  the  cheeks  or 
chin  (which  have  been  recommended  in  bygone  days)  were 
useless ;  pressure  with  the  thumbs  on  the  back  teeth, 
combined  with  elevation  of  the  chin,  succeeded  only  a  few 
times ;  depression  of  the  chin  at  the  same  time  that  the 
tliumbs  pressed  away  the  masseters  from  the  interior  of  the 
mouth  was  rather  more  successful ;  depression  of  the  chin 
and  pressure  on  the  coronoid  processes  from  before  back- 
wards, with  the  thumbs  in  the  mouth,  effected  reduction 
constantly  and  with  ease. 

In  Xovember,  1883,  Mr.  Golding  Bird  brought  before 
tlie  Clinical  Society  a  man,  aged  twenty-two,  in  whom  an 
unreduced  dislocation  of  both  condyles  had  existed  for 
eighteen  weeks.  After  breaking  down  adhesions,  Mr.  Bird 
succeeded  in  reducing  the  right  condyle,  and  subsequently 
the  left,  by  Xelaton's  method  of  pressing  directly  upon  the 
coronoid  processes,  followed  by  drawing  up  the  chin. 

In  all  cases  of  dislocation  the  administration  of  chloro- 
form will  facilitate  the  reduction,  but  it  is  not  necessary  in 
recent  cases.  In  old- standing  cases  it  should  invariably  be 
had  recourse  to,  since  the  operation  will  necessarily  be  both 
painful  and  prolonged,  in  consequence  of  the  formation  of 
fibrous  adhesions. 

When  reduction  has  been  effected,  the  precaution  should 
be  taken  to  limit  the  movements  of  the  jaw  for  a  week  or 
two,  by  the  use  of  the  four-tailed  bandage  used  in  cases  of 
fracture  of  the  jaw. 

After  a  week  or  ten  days  passive  movements  should  be 
carefully  employed  to  prevent  the  danger  of  any  degree  of 
anchylosis.  Massage  over  the  region  of  the  joint  might  in 
some  cases  be  useful. 

In  the  Lancet  of  April  14,  1883,  Mr.  Pughe,  of  Liverpool, 
has  reported  the  case  of  a  boy  of  four  years,  in  whom  the 
condyle  was  dislocated  by  a  blow  on  the  chin  two  years 
before,  and  in  whom  anchylosis  between  the  condyle  and 


88  DISLOCATION   OF   THE   LOWER  JAW. 

the  zygoma  had  taken  place,  causing  complete  closure  of 
the  jaws.  Mr.  Pughe  resected  the  condyle,  with  the  result 
that  the  patient  could  open  his  mouth  to  the  extent  of  an 
inch,  but  had  no  lateral  movement. 

Treatment  of  Eccurrmg  Dislocation. — In  individuals  liable 
to  recurring  dislocation  of  the  jaw  (like  the  woman  mentioned 
by  Putegnat,  whose  jaw  was  dislocated  once  a  month),  some 
elastic  support  for  the  chin  should  be  employed,  and  care  be 
taken  not  to  open  the  mouth  too  widely. 

Borison  of  Algiers  {Gaz.  MSdicale  dc  Nantes)  reports  a 
case  of  bilateral  dislocation  which  recurred  twenty-two 
times  in  one  year.  The  patient  was  radically  cured  by 
keeping  the  jaw  absolutely  immobile,  with  milk  diet  and 
faradization  of  the  temporal  and  masseteric  regions. 

In  some  cases  an  operation  may  be  necessary.  Thus  F. 
Marsh  {Brit.  Med.  Journ.  1892)  reports  a  case  of  recurring 
bilateral  dislocation  treated  by  operation.  He  cut  down 
upon  the  left  joint,  and  stitched  the  fibro-cartilage  to  the 
periosteal  attachment  of  the  capsule  to  the  zygoma,  a  method 
previously  adopted  by  Mr.  Aunandale  for  the  treatment  of 
cases  of  sub-luxation  of  the  temporo-maxillary  joint  (see 
"  Diseases  of  Temporo-maxillary  Articulation  ").  Four  months 
afterwards  the  right  side  was  similarly  treated.  Both 
wounds  healed  well,  and  eighteen  months  afterwards  the 
patient  had  had  no  recurrence  of  the  dislocation. 


CHAPTEE  VII. 

INFLAJDIATORY  DISEASES  OF  THE  JAWS. PERIOSTITIS  AND 

ABSCESS. 

Inflammatory  diseases  of  the  jaws  are  very  common,  in 
fact,  inflammation  occurs  more  frequently  in  these  bones 
than  in  any  others,  and  the  reason  for  this  is  not  far  to  seek. 
The  relation  of  the  teeth  to  the  jaws  is  a  most  intimate  and 
important  one.  Between  each  tooth  and  the  jaw,  lining  the 
tooth-socket,  is  a  layer  of  tissue  frequently  termed  the 
alveolar  or  alveolo-dental  periosteum.  It  is  in  this  perios- 
teum, situated  between  the  teeth  and  the  lower  jaw  that 
the  large  majority  of  inflammatory  affections  of  the  jaws 
■commence.  In  some  cases  the  alveolar  periosteum  of  all 
the  teeth  is  affected  simultaneously,  whereas  in  other  cases 
the  periosteum  of  only  one  or  two  teeth  may  be  affected. 
Hence  we  may  divide  the  cases  into  diffused  and  localised. 
(a)  Diffused  inflammation  of  the  edveolar  ijeriosteum. 

1.  A  striking,  and  at  one  time  very  common,  example 
of  this  diffused  periostitis  occurs  in  persons  exposed  to  the 
fumes  of  phosphorus.  It  is  well  known  that  this  form  of 
periostitis  can  only  arise  in  those  persons  whose  teeth  are 
in  an  unhealthy  condition,  so  tliat  the  fumes  can  reach  the 
alveolar  periosteum.  In  all  cases  of  so-called  phosphorus- 
necrosis  the  trouble  always  commences  in  the  alveolar 
periosteum,  and  it  is  by  the  extension  of  the  inflammation 
to  the  rest  of  the  jaw  that  the  death  of  a  greater  part  or  of 
the  whole  of  the  bone  takes  place.  It  will  be  more  con- 
venient to  consider  this  subject  at  greater  length  in  the 
chapter  on  necrosis  (see  Chap.  VIII.). 

2.  A   condition    very   similar  to  this  may   be    brought 


90  IXFLAMMATOEY   DISEASES    OF  THE    JAWS. 

about  by  the  administration  of  mercury  in  doses  large 
enough  to  produce  salivation.  In  this  case  it  is  quite  pro- 
bable that  the  excessive  ptyalism  is  the  real  cause,  as  other 
drugs  causing  salivation  have  been  followed  by  similar  results. 

3.  In  strumous  children  we  sometimes  see  a  diffused 
periostitis,  generally  of  the  lower  jaw,  which  may  lead  to 
very  extensive  necrosis.  It  is  very  doubtful,  however, 
whether  this  is  a  tubercular  periostitis.  In  all  probability 
it  is  not  similar  to  the  periostitis  which  may  occur  in  other 
parts  of  the  body  in  strumous  children. 

Mr.  Stanley,  in  his  work  on  "  Diseases  of  the  Bones"  (p.  71), 
alludes  to  cases  of  this  kind,  although  he  does  not  appear  to 
connect  them  with  a  strumous  diathesis.  He  says  :  "  A  large 
portion  of  the  lower  jaw  in  young  persons  occasionally 
perishes  without  any  previous  derangement  of  health,  local 
injury,  or  other  apparent  cause.  But  in  some  cases  an 
aching  in  the  bone  has  preceded  the  death  of  it.  Such 
examples  of  necrosis  usually  occur  in  early  life,  between  the 
fourth  and  twentieth  years,  but  rarely  later." 

4.  In  persons  subject  to  rheumatism,  attacks  of  diffused 
periostitis  are  by  no  means  uncommon.  In  such  cases  the 
periostitis  does  not  tend  to  go  on  to  suppuration  and  necrosis, 
but  organises  and  forms  a  thickening  of  the  jaw. 

5.  Chronic  suppuration  may  occur  at  the  necks  of  the 
teeth,  leading  to  progressive  necrosis  of  the  alveolar  margin. 
In  this  way  the  fang  of  the  tooth  is  exposed,  and  finally  the 
tooth  falls  out.  This  condition  is  termed  "  pyorrhoea  alveo- 
laris,"  or  sometimes  "  Eigg's  disease."  Its  pathology  is  very 
obscure,  and  the  reader  is  referred  to  the  excellent  discus- 
sion on  the  subject  in  Tomes'  "  System  of  Dental  Surgery." 
According  to  most  observers,  the  inflammation  commences 
in  the  alveolo-dental  periosteum,  and  is  probably  septic  in 
its  nature,  and  caused  by  the  deposit  of  tartar. 

6.  Magitot,  in  a  paper  read  before  the  Academy  of 
Medicine  of  Paris  (1882),  has  described  a  form  of  alveolar 
periostitis  which  he  considers  pathognomonic  of  diabetes. 
Without  going  so  far  as  this,  Dr.  Pavy  recognises  the  affec- 
tion in  the  following  extract  from  his  work  on  diabetes  : 


SYMPTOMS  AND  TREAT.MENT.  91 

"  The  teeth  are  not  unfrequently  observed  to  "become  loosened 
in  diabetes,  and  it  may  be  even  to  snch  an  extent  as  easily 
to  drop  out.  There  is  evidently  some  direct  connection 
between  this  phenomenon  and  the  disease.  It  seems  as  if 
the  morbid  condition  of  the  system  prevailing  interfered  with 
the  nutritive  action  going  on  in  the  fang  and  its  socket,  and 
so  led  to  the  result.  It  is  only  when  the  symptoms  are 
allowed  to  run  on  in  a  severe  form  that  it  is  noticed,  and, 
supposing  the  teeth  to  have  become  already  loosened,  I  have 
known  them  to  again  become  firm  upon  the  disease  being 
controlled  by  treatment." 

Sijmptomfi. — In  cases  of  diffused  alveolar  periostitis,  the 
earliest  symptom  is  an  uneasy  sensation  in  the  teeth.  This 
gradually  becomes  worse,  and  tiie  least  pressure  upon  them 
causes  excruciating  pain.  The  pain  is  often  worse  at  night. 
There  is  redness  and  swelling  of  the  face,  together  with  a 
general  constitutional  disturbance.  On  examination,  the 
teeth  are  found  to  be  raised  somewhat  from  their  sockets 
and  loosened.  The  subsequent  course  of  events  will  depend 
to  a  great  extent  upon  the  cause  of  the  inflammation.  Thus 
in  the  periostitis  due  to  phosphorus  fumes  or  to  mercury 
salivation,  extensive  suppuration  and  necrosis  may  result. 
In  strumous  patients  a  similar  though  usually  less  exten- 
sive necrosis  may  take  place.  In  rheumatic  cases  sup- 
puration is  very  unusual.  As  a  rule  a  general  thickening 
of  the  jaw  takes  place. 

Treatment. — As  this  affection  often  depends  upon  a  general 
unhealthy  condition,  our  attention  must  be  directed  to  this 
state.  Thus  in  rheumatic  periostitis  the  treatment  of 
rheumatism  should  be  carried  out.  In  strumous  subjects 
cod-liver  oil,  prejparations  of  iron  and  of  the  hypophosphites, 
and  suitable  climate,  should  be  recommended. 

Local  treatment  is  also  very  important.  In  the  early  stages 
counter-irritation  with  tincture  of  iodine  or  tannin  powder 
may  be  beneficial.  Local  depletion  by  leeches  may  be  useful. 
It  is  most  important  to  wash  out  the  mouth  frequently  with 
antiseptic  mouth-washes.  These  are  especially  indicated 
where  there  is  chronic  suppuration  around  the  necks  of  the 


92  INFLAMMATORY  DISEASES   OF    THE    JAWS. 

teeth.  In  severe  cases  incisions  through  the  gums  and 
periosteum  may  be  beneficial,  and  in  cases  where  suppura- 
tion has  commenced  it  is  most  important  to  make  free 
incisions  to  relieve  tension. 

(h)  Localised  infiammation  of  the  alveolar  jyeriosteicm. 

These  cases  very  naturally  fall  into  two  groups  :  the  acute 
inflammation,  which  frequently  goes  on  to  suppuration,  and 
forms  an  ordinary  alveolar  abscess  or  an  abscess  in  the 
substance  of  the  jaws  ;  the  chronic  inflammation,  rarely 
proceeding  to  abscess,  but  causing  suppuration  along  the 
necks  of  the  teeth,  where  the  gum  and  alveolar  periosteum 
meet. 

Alveolar  Abscess. — As  a  rule  this  arises  in  connection  with 
some  carious  changes  in  a  tooth,  and  is  probably,  in  the  great 
majority  of  cases,  due  to  the  introduction  of  micro-organisms. 
The  germs  may  spread  from  the  carious  patch  through  the 
pulp,  to  the  alveolar  periosteum,  or  they  may  gain  their 
entrance  at  the  junction  of  the  alveolar  periosteum  and  gum 
around  the  neck  of  the  tooth.  In  some  cases  an  abscess 
appears  to  arise  without  any  morbid  condition  of  the  teeth, 
and  at  present  it  is  impossible  to  account  for  the  origin  of 
such  abscesses  satisfactorily. 

The  progress  of  an  alveolar  abscess  is  thus  described  by 
Tomes  :  "  If  the  progress  of  the  disease  be  unarrested,  the 
periosteum  becomes  detached  from  the  cementum,  and  the 
point  of  separation  usually  commences  at  and  extends  from 
the  foramen  in  the  root  of  the  tooth.  Into  the  interval  thus 
formed  pus  is  poured  from  the  separated  surface  of  the 
periosteum.  The  fang  at  this  part  loses  its  vitality,  and  is 
bathed  in  pus,  the  quantity  of  which  is  gradually  increased, 
space  being  gained  in  the  alveolus  for  the  dilatation  of  the 
abscess  at  the  expense  of  the  bone.  The  extent  to  which  the 
alveolus  becomes  excavated  will  vary  with  each  case.  It 
may  be  hollowed  out  to  a  very  limited  extent  around  the 
apex  of  the  root,  or  a  large  cavity  may  be  formed.  The 
size  of  the  abscess  will  depend  upon  the  activity  of  the 
symptoms,  the  time  the  pus  is  pent  up,  and  the  state  of  the 
health  of  the  patient.     So  soon  as  suppuration  is  established 


ALVEOLAl;    ABSCESS.  93 

a  process  is  set  up  for  liberating  the  secretion.  Either  the 
periosteum  becomes  detached  from  the  neck  of  the  tooth, 
and  the  pus  finds  its  way  by  the  side  of  the  socket  and 
passes  out  at  the  edge  of  the  gum,  or  a  perforation  is  made 
in  the  wall  of  the  alveolus,  through  which  the  contents  of 
the  abscess  pass  into  the  substance  of  the  gum.  If  the 
disease  is  left  to  run  its  own  course,  the  contents  of  the 
abscess  will  sooner  or  later  find  their  way  to  the  surface 
and  escape." 

The  direction  which  the  pus  of  an  alveolar  abscess 
may  take  is  very  variable.  According  to  Salter  the 
commonest  position  for  the  matter  to  point  is  "  on  the 
outer  surface  of  the  jaw  at  a  point  corresponding,  as  nearly 
horizontally  as  may  be,  with  the  extremity  of  the  fang  of 
the  affected  tooth,  and  piercing  the  gums  within  the  mouth.^' 
But  the  matter  may  find  its  way  in  other  directions.  Thus 
both  Tomes  and  Salter  mention  the  tendency  of  pus,  derived 
from  an  upper  incisor  tooth,  to  burrow  between  the  bone 
and  the  periosteum  of  the  hard  palate  and  open  upon  tlie 
surface  of  the  soft  palate.  The  former  also  states  that 
occasionally  the  pus  separates  the  periosteum  from  one  side 
of  the  hard  palate,  and  forces  it  down  to  a  level  with  the 
teeth.  Abscesses  connected  with  the  upper  incisor  teetli 
may  also  point  within  the  nostrils  by  small  orifices  present- 
ing little  teat-like  elevations,  which  will  be  at  once  detected 
on  a  careful  examination  of  the  nostrils.  The  patient's 
attention  will  have  probably  been  directed  to  the  occasional 
discharge  of  pus  from  the  nose,  and  the  case  may  be 
erroneously  treated  as  one  of  oz^na. 

An  abscess  connected  with  any  tooth  may  point  on  the 
face,  and  in  the  case  of  the  lower  jaw  beneath  the  chin.  It 
may  burst  into  the  antrum,  but  this  is  only  likely  in  cases 
where  the  disease  commenced  in  the  bicuspid  or  molar  teeth 
of  the  upper  jaw.  Tomes,  however,  mentions  the  case  of  an 
abscess  in  the  antrum  being  due  to  a  central  incisor  of 
the  upper  jaw.  According  to  Tomes,  collections  of  matter, 
formed  about  the  wisdom  teeth,  pass  between  the  muscles 
and  bone  and  escape  at  the   angle  of  the  jaw,  or   may  pass 


94  IXFLAMMATORY    DISEASES    OF    THE    JAWS. 

forwards  inside  the  mouth  and  open  near  the  canines ;  on 
the  other  hand  they  may  pass  backwards  and  open  into  the 
fauces. 

Abscesses  in  connection  with  the  molar  teeth  may  burrow 
extensively  in  the  neck,  no  doubt  assisted  by  gravity,  and 
may  even  open  below  the  clavicle. 

Sfjnqjtoms. — There  is  at  first  a  dull,  uneasy  sensation 
which  can  scarcely  be  called  pain.  This  is  relieved  by 
biting  upon  the  tooth,  but  as  soon  as  the  pressure  is  with- 
drawn the  uneasy  sensation  returns.  This  is  soon  followed 
by  a  dull  heavy  pain,  and  the  tooth  appears  to  be  raised 
slightly  from  its  socket.  The  pain  soon  becomes  of  an 
acute  throbbing  kind,  and  the  constitutional  symptoms  are 
occasionally  severe,  amounting  to  high  fever  and  delirium. 
On  examination  there  is  found  swelling  and  tenderness  of 
the  gum  and,  according  to  Tomes,  an  early  but  evanescent 
symptom  is  a  well-defined  red  ring  encircling  the  neck  of 
the  tooth.  The  jaw  becomes  rapidly  swollen  and  the  face 
consequently  distorted.  The  acute  symptoms  continue 
until  the  pus  has  found  an  exit,  and  then  as  rapidly 
subside. 

Complications  and  Sequekc—The  large  majority  of 
alveolar  abscesses,  whether  treated  by  a  surgeon  or  allowed 
to  run  their  own  course,  terminate  favourably  without 
any  serious  complication.  Occasionally,  however,  in  cases 
that  have  not  been  properly  treated,  very  grave  results  may 
follow.  Thus,  Mr.  Howse,  in  the  Medical  Times  and  Gazette 
for  1876,  relates  the  history  of  a  case  of  pytemia  occurring 
in  a  child  four  and  a  half  years  old,  following  an  alveolar 
abscess  in  the  lower  jaw\ 

On  two  occasions  I  have  known  death  result  from  a  low 
form  of  cellulitis  spreading  between  the  muscles  of  the 
neck  and  leading  to  oedema  of  the  larynx,  distinctly  trace- 
able to  neglected  alveolar  abscess,  in  patients  whose  con- 
stitution had  been  greatly  damaged  by  intemperance.  In 
the  first  I  had  made  free  incisions  in  the  mouth  and  neck, 
but  oedema  glottidis  supervened  in  the  night  and  proved 
iatal.     In    the    second    I    took    the    precaution  of    freely 


TltEATMENT    OF    INFLAMMATION".  95 

scarifying  the  mucous  membrane  of  the  throat,  but  here 
again  unfortunately  I  was  not  summoned  wlien  the  breath- 
ing became  urgent.  A  similar  disastrous  case  is  recorded 
by  Dr.  Harrison  Allen  in  the  Dental  Cosmos  for  1874. 

An  interesting  case  is  recorded  by  Mr.  Pearce  Gould, 
in  which  the  mischief  started  in  an  alveolar  abscess  of 
the  lower  jaw.  The  pus  extended  backwards  to  the  ptery- 
goid region,  causing  thrombosis  of  the  venous  plexus  there, 
and  later  the  thrombosis  extended  to  the  cavernous  sinuses, 
causing  death  in  a  comatose  state. 

A  not  uncommon  complication  of  alveolar  abscess  is 
inflammation  of  the  submaxillary  lymphatic  glands,  which 
sometimes  goes  on  to  suppuration.  This  is  said  to  occur 
with  special  readiness  in  strumous  individuals. 

Treatment. — The  first  step  indicated  is  to  get  rid  of  the 
source  of  the  inflammatory  trouble,  which  is  nearly  always 
a  septic  focus  in  the  carious  tooth.  Any  stopping  should 
be  removed  and  the  pulp  cavity  and  root  canals  cleared  out, 
or  a  hole  may  be  drilled  into  the  pulp  cavity  through  the 
side  of  the  tooth  so  as  to  give  exit  to  any  accumulated  fluid 
(see  paper  on  "  Ehizodontresis,"  by  Mr.  Hulme  :  British 
Journal  of  Dental  Science,  April,  1865). 

When  the  dental  periosteum  becomes  involved,  local 
blood-letting  may  be  very  beneficial  in  cutting  short  the 
inflammation ;  one  or  two  leeches  should  be  applied  to 
the  gum  through  a  leech-tube,  and  the  subsequent  fomen- 
tation of  the  part,  by  means  of  hot  water  held  in  the  mouth, 
may  give  relief. 

In  many  cases,  in  spite  of  all  treatment,  suppuration 
takes  place.  When  matter  has  formed  and  is  finding  a 
precarious  exit  by  the  side  of  the  tooth,  which  is  certainly 
dead  and  will  only  prove  a  source  of  irritation,  its  imme- 
diate extraction  is  the  best  practice.  But  when,  as 
frequently  happens,  the  matter  has  perforated  the  alveolus 
and  passed  into  the  substance  of  the  gum  so  as  to  produce 
an  elastic  fluctuating  tumour  between  the  teeth  and  the 
cheek,  a  free  incision  into  it  is  the  best  and  only  mode  of 
treatment.     If  possible  the  knife  should  be  carried  right 


96  IXFLAMMATOEY    DISEASES    OF    THE    JAWS. 

through  the  spongy  bone  forming  the  wall  of  the  abscess 
cavity,  and  in  these  cases  if  the  hole  in  the  alveolus  is 
sufficiently  large  to  give  free  exit  to  the  pus,  the  teeth  may 
be  eventually  saved.  I  know  of  no  reason  for  delaying  the 
incision  until  the  gum  has  become  distended  with  pus, 
though  the  practice  has  its  advocates.  So  soon  as  inflam- 
matory swelling  takes  place,  an  incision  will  do  good  by 
relieving  congestion  and  giving  exit  to  exudations ;  and  I 
have  never  seen  reason  to  regret  an  early  and  free  incision 
in  such  cases.  A  sharp  scalpel  or  small  bistoury  is  the 
best  instrument  for  the  operation,  the  ordinary  gum-lancet 
being  unsuitable  and  inconvenient  for  the  purpose,  and  no 
damage  to  neighbouring  parts  can  happen  if  the  edge  of  the 
knife  is  directed  towards  the  bone.  I  have  once  known 
the  facial  artery  wounded  from  within  the  cheek  from 
neglect  of  this  precaution. 

There  is  a  popular  notion,  which  has  received  some 
support  at  the  hands  of  certain  members  of  the  profession, 
that  extraction  of  a  tooth  must  not  be  performed  during  the 
stage  of  active  inflammation  of  the  alveolus.  I  know  of  no 
foundation  for  this  statement,  which  is  entirely  devoid  of 
truth,  and  yet  it  has  formed  the  ground  for  an  action  against 
an  eminent  member  of  the  dental  profession.  As  a  rule, 
extraction  of  the  teeth  is  not  necessary,  and  indeed  our 
endeavour  should  be  to  save  the  tooth  ;  but  in  some  cases  it 
is  important  that  the  tooth  should  be  removed,  either  on 
account  of  its  septic  nature  or  of  its  interference  with  the 
drainage  of  the  abscess  cavity.  It  may  be  well,  therefore, 
to  put  on  record  the  statement  of  the  President  of  the 
"  Association  of  Surgeons  practising  Dental  Surgery "  in 
answer  to  the  question  "  Is  it  right  to  refuse  to  extract  a 
carious  and  aching  tooth  on  account  of  the  acuteness  of  the 
periosteal  and  maxillary  inflammation  which  its  presence 
has  excited  ? "  The  president  (Mr.  Cattlin,  E.E.C.S.)  "  was 
glad  that  Mr.  Owen  had  brought  under  discussion,  in  his 
practical  paper,  an  unskilful  kind  of  jjractice  which  greatly 
increased  human  suffering,  and  was  often  very  injurious  to 
the  patient  in  after-life.      It  was  the  erring  practice  of  some 


TREATMENT    OF    ALVEOLAR    ABSCESS.  97 

to  wait  until  the  iutiammation  subsided  ;  but,  if  the  tooth 
be  retained,  the  swelling,  as  a  rule,  rapidly  extends  to 
adjoining  parts,  and  sometimes  causes  necrosis,  occasionally 
infiltrating  into  muscle,  restricting  the  movements  of  the 
jaw,  and  often  ending  in  abscess,  which,  bursting  externally, 
permanently  disfigures  the  face "  {Medical  Press  aiul 
Circular,  January  12,  1 8  8  i ). 

In  cases  of  abscess  arising  from  the   upper  incisor  teeth 

and  extending  along  the   palate,  a  free   and   early  incision 

is  even  more  necessary  than  in  the  ordinary  form  of  abscess, 

since  extensive  necrosis  and  exfoliation  of  the    hard   palate, 

with   consequent  perforation,   may   not    improbably    result 

from   the   delay.      The   same  rule   holds   good    also  in  all 

cases  of  matter  pointing  within  the   cavity  of   the   mouth  ; 

but  where,  as  has  already  been  mentioned,  the  matter  shows 

a  tendency  to  point  on  the  skin  of  the  face  or  neck,    every 

means  should  be  taken  to  avert,  if  possible,  the   opening  in 

this  situation,  and  to  insure  an  exit  for  the  matter  within 

the  mouth.       It  may  be  well  to  notice  here,  that  the  cause 

of  the  abscess  in  these  cases  is  not  unfrequently  overlooked, 

owing  to   the   distance  between   the   tooth   and  the    point 

where  the  matter  appears,  and  that  in  all  cases  therefore 

of  abscess  about  the  jaw  or  neck,  it   is   well   to  investigate 

carefidly  the  state  of  the  mouth.     No  greater  mistake   can 

be   made   than  to   encourage  the   pointing  of  an  alveolar 

abscess  on  the  surface  of  the  skin  by  poulticing.     During 

the  early  and  acute  stages  of  the  inflammation,  the  warmth 

of  a  poultice  may  be  grateful  to  the  patient,  and  if  applied 

for  a  few  hours  will  do  no  harm,  though  I  should  myself 

greatly  prefer  the  application  of  extract  of   belladonna  and 

glycerine   in   equal  proportions.      Even   when  the   skin  is 

already  reddened  and  adherent    to  the  bone,  its  breaking 

may  be  avoided  (provided  a  free  exit   for  the  discharge  of 

matter  into  the  mouth  has  been   secured)  by  painting   the 

surface  with  flexile  collodion  or  with  tincture  of  iodine,  all 

warm  applications  being  discarded. 

The  sinuses  left  after  an  alveolar  abscess  has  burrowed 
through  the  integuments,  remain  open  so  long  as  the  cause 

G 


98  INFLAMMATORY    DISEASES    OF    THE   JAWS. 

of  irritation  is  untouclied,  and  the  orifice,  though  contracted, 
never  closes,  being  surrounded  by  granulations  which  some- 
times grow  to  a  large  size.  I  had  under  my  care  a  girl 
who  was  brought  to  me  for  the  supposed  growth  of  a  horn 
from  her  chin,  and  the  appearance  was  not  unlike  one  of 
the  horn-like  growths  of  cuticle  occasionally  met  with.  It 
proved  to  be  nothing  more  than  a  growth  of  epithelium  on 
the  top  of  long  granulations  around  a  fistulous  opening,  due 
to  the  presence  of  a  stump  in  the  lower  jaw,  the  bone 
having  been  perforated  by  the  abscess.  The  successful 
treatment  of  these  sinuses,  like  those  dependent  upon  the 
presence  of  bone  elsewhere,  can  only  be  insured  by  the 
extraction  of  the  offending  tooth  or  stump.  In  these  cases 
the  fang  is  necrosed  and  forms  a  sequestrum  in  the  same 
way  as  a  piece  of  bone,  and  will  keep  up  irritation  so  long 
as  it  is  allowed  to  remain.  The  distance  from  the  jaw  at 
which  an  alveolar  abscess  may  occasionally  point  not  un- 
frequently  leads  to  mistakes  in  diagnosis  and  treatment, 
particularly  of  the  resulting  sinus.  I  have  on  several 
occasions  known  a  sinus,  at  some  distance  below  the  lower 
jaw,  treated  by  injections  when  the  fang  of  a  tooth  was 
keeping  up  irritation,  and  Salter  has  seen  openings  an  inch 
below  the  clavicle  dependent  upon  the  same  cause.  I  have 
once  found  the  diseased  fang  so  deeply  buried  and  over- 
lapped by  the  neighbouring  teeth  that  it  could  only  be 
detected  by  careful  probing  from  the  mouth,  and  it  was 
necessary  to  remove  the  adjacent  teeth  in  order  to  reach  the 
cause  of  the  sinus. 

Abscesses  in  the  Stibstance  of  the  Jaws. — Abscesses  may 
form  in  the  substance  of  the  upper  or  lower  jaw  as  a  conse- 
quence of  decayed  teeth,  but  differing  from  ordinary  alveolar 
abscess  in  the  absence  of  any  tendency  to  find  an  exit  by 
the  socket  of  the  tooth.  In  the  upper  jaw  this  affection  has 
been  confounded  with  the  so-called  "  abscess  of  the  antrum," 
which  is  more  properly  an  empyema,  and  which  will  be 
subsequently  discussed ;  and  Otto  Weber  (Allgemeinen  tmd 
speciellen  Ghirurgie,  iii)  strongly  maintains  that  abscess  may 
form  in  the  wall  of   the   antrum,   but  perfectly  separated 


ABSCESSES    IN    THE    JAW.  99 

from  it,  both  by  the  periosteum  and  the  mucous  membrane, 
or  sometimes  by  a  plate  of  bone. 

Abscess  in  the  substance  of  the  lower  jaw  has  been  more 
frequently  met  with  than  in  the  upper  jaw,  and  in  most 
cases  the  abscess  is  caused  by  a  decayed  tooth.  Thus,  in 
a  lady  whom  I  saw  with  Mr.  G.  Bateman,  there  was  a 
fluctuating  swelling  of  the  lower  jaw  in  the  incisive  region, 
from  which  I  evacuated  by  incision  a  quantity  of  offensive 
inspissated  pus,  due  to  irritation  from  incisor  teeth  which 
had  been  extracted  some  time  before  I  saw  the  patient. 

i\nother  mode  in  which  abscess  may  be  formed  in  both 
the  upper  and  lower  jaws  is  by  the  suppuration  of  a  "  den- 
tigerous  cyst "  connected  with  non-developed  or  imperfectly 
developed  teeth.  A  remarkable  case  of  this  kind  is  reported 
by  Weber  {op.  rit.),  in  which  a  woman,  aged  twenty-five, 
shortly  after  the  partial  eruption  of  a  wisdom  tooth,  found 
a  tumour  forming  on  the  left  side  of  the  jaw,  which  in  a 
year  extended  from  the  mental  foramen  to  beyond  the  angle. 
The  bone  gave  a  crackling  sound  when  pressed  upon,  and 
in  one  or  two  situations  appeared  to  be  entirely  absorbed. 
An  incision  was  made  over  it,  and  on  opening  the  tumour 
three  ounces  of  thick  flaky  pus  poured  out.  Part  of  the 
wall  was  removed,  and  the  patient  made  a  good  recovery. 

Probably  the  case  described  by  Liston  in  his  "  Elements 
of  Surgery  "  (p.  4 1 9),  in  which  he  mentions  that  osteo- 
sarcoma may  supervene  on  "  spina  ventosa  "  of  the  lower  jaw, 
is  an  instance  in  point.  The  case  was  that  of  a  young  man, 
aged  twenty-one,  who  had  an  abscess  of  the  lower  jaw  in 
the  molar  region,  which  was  evacuated  through  the  mouth 
and  by  means  of  a  seton.  Two  years  after  the  abscess 
refilled,  and  again  after  another  year;  osteo-sarcoma  then 
developed,  necessitating  the  removal  of  half  the  jaw. 

Localised  Chronic  Infiammation  of  the  Alveolar  Periosteum. 
— This  condition  is  very  similar  to  the  diffused  inflammation 
of  the  alveolar  periosteum,  but  only  one  or  two  teeth  are 
affiected.  The  trouble  generally  commences  around  the 
neck  of  a  tooth,  being  probably  a  septic  inflammation  due  to 
the  deposit  of  tartar.     The  dental  periosteum  is  gradually 


100  INTLAMMATOKY  DISEASES    OF   THE   JAWS. 

involved,  and  finally  the  tooth  may  drop  out.  This  condi- 
tion comes  chiefly  within  the  province  the  of  dental  surgeon. 

Although  the  irritation  caused  by  decayed  teeth  is  very 
prone,  as  we  have  seen,  to  cause  acute  inflammation  terminat- 
ing in  an  abscess,  yet  sometimes  the  inflammatory  process 
may  be  much  less  acute,  and  may  terminate  in  a  different 
manner.  The  inflammation,  commencing  in  the  alveolar 
periosteum,  spreads  through  the  substance  of  the  jaw  to  its 
periosteum.  This  latter  becomes  inflamed,  and  gradually  an 
effusion  of  lymph  infiltrates  the  bone  and  periosteum,  leading 
to  the  formation  of  a  distinct  tumour.  This  is  slowly 
absorbed  on  the  early  removal  of  the  tooth,  but  if  the  irri- 
tation be  allowed  to  continue  the  effusion  will  become 
organised  into  fibrous  tissue,  and  a  very  serious  affection 
may  be  thus  produced. 

From  an  attentive  examination  of  numerous  examples  of 
fibrous  tumour  of  the  lower  jaw,  both  before  and  after 
removal,  I  feel  sure  that  the  majority  originate  in  the 
manner  here  described.  This  condition  is  met  with  only  in 
the  lower  jaw.  In  the  upper  jaw,  owing  to  the  thinness  of 
the  bone,  the  inflammatory  exudation  readily  finds  an  exit 
on  the  surface,  and  thus  the  injurious  effects  of  prolonged 
tension  are  averted. 

The  two  following  cases  are  examples  of  this  form  of 
chronic  inflammation  occurring  in  the  lower  jaw  : 

I  had  in  the  summer  of  1867  a  patient  under  my  care — 
a  boy,  aged  fourteen — who  was  suffering  from  an  enlarge- 
ment of  the  lower  jaw,  due  to  an  expansion  of  its  wall  by  a 
growth  evidently  connected  with  a  carious  permanent  first 
molar  tooth.  I  had  the  peccant  tooth  extracted,  but  the 
enlargement  of  the  jaw  continued.  In  August  some  sup- 
puration occurred,  and  an  abscess  broke  behind  the  angle  of 
the  jaw ;  but  this  soon  healed,  and  in  November  he  was 
perfectly  free  from  pain  and  able  to  open  the  mouth 
thoroughly.  I  was  anxious  to  perforate  the  jaw  from  the 
mouth,  so  as  to  give  exit  to  any  fluid  contained  in  it  and 
extract  any  solid  material  which  might  exist,  but  the  parents 
would  not  consent  to  any  surgical  interference.     The  face 


TUBERCULAR    PERIOSTITIS.  101 

had  in  May,  1868,  considerably  diminished  in  size,  but 
there  was  still  a  difference  between  the  two  sides.  Two 
years  later,  however,  I  could  detect  no  difference  between 
them. 

In  a  little  girl  of  seven,  also,  whom  I  saw  in  1872,  with 
great  enlargement  of  the  right  side  of  the  lower  jaw,  in  six 
years  the  part  had  resumed  its  natural  shape. 

It  was  pointed  out,  at  the  commencement  of  this  chapter, 
that  the  large  majority  of  the  inflammatory  affections  of  the 
jaws  started  in  the  alveolo-dental  periosteum.  Certain 
forms  of  periostitis  may  arise,  however,  quite  apart  from  the 
teeth.  Sypliilitic  'periostifAs  is  a  common  example  of  this, 
and  leads  to  the  formation  of  nodes  here  as  in  other  parts. 
The  palate  is  especially  liable  to  these  swellings,  which  are 
due  to  effusion  between  the  periosteum  and  the  bone,  and 
which,  if  left  untreated,  will  as  surely  lead  to  necrosis  as 
the  more  acute  forms.  Mercury  is  inadmissible  in  these 
cases,  but  iodide  of  potassium  in  full  doses  will  rapidly 
remove  the  swelling,  and  restore  the  periosteum  to  a 
healthy  state. 

Tuhercular  periostitis  is  occasionally  met  with  in  the 
jaws,  and  it  may  resist  all  medicinal  treatment.  In  such 
cases  an  incision  should  be  made  into  the  swelling,  and  all 
the  diseased  periosteum  and  bone  be  scraped  away  with  a 
sharp  spoon. 

Dr.  Gross,  of  Philadelphia,  has  called  attention  to  a  form 
of  neuralgia  occurring  in  edentulous  jaws,  and  dependent 
upon  thickening  and  induration  of  the  alveolar  margin,  by 
which  the  remains  of  the  dental  nerves  become  compressed 
and  irritated.  He  recommends  removal  of  the  margin  of 
the  alveolus  with  cutting  forceps,  and  speaks  highly  of  the 
practice.  Having  seen  the  proceeding  adopted  on  several 
occasions  by  Mr.  Erichsen,  and  having  used  it  myself,  I 
think  that  there  are  undoubtedly  cases  of  neuralgia  which 
are  relieved  by  the  treatment,  but  that  it  is  by  no  means 
of  universal  application  in  cases  of  neuralgia  of  the  fifth 
nerve. 

In  the  Archiv  fur    PatJiologische    Anatomie,    xviii,   347, 


102  INFLAMMATOKY   DISEASES    OF   THE   JAWS. 

Dr.  H.  Senftleben  has  given  an  elaborate  description  of 
what  he  terms  acute  o'heumatic  j^eriostitis  of  the  lower  jaw. 
It  is  impossible  to  explain  its  pathology,  or  even  to  say  how 
it  differs  essentially  from  the  ordinary  acute  diffused  perios- 
titis. He  says  that  it  attacks  perfectly  healthy  and  robust 
individuals  with  good  teeth,  after  severe  cold,  commencing 
with  violent  toothache  along  one  side  of  the  lower  jaw,  con- 
siderable and  very  often  intense  fever,  swelling  of  the  cheek 
and  gums,  difiFxCulty  in  chewing,  &c.  Active  depletion  is 
recommended,  and  an  early  incision  if  matter  forms. 
JSTecrosis  is  a  very  frequent  consequence. 


CHAPTER  VIII. 

NECROSIS    OF    THE    JAWS. 

Although  it  is  convenient  to  consider  the  subject  of  necrosis 
of  the  jaws  in  a  special  chapter,  yet  it  must  be  clearly 
understood  that  necrosis  does  not  in  itself  constitute  a 
disease,  but  is  a  result  of  previous  inflammatory  disease  of 
a  bone.  In  nearly  all  cases  of  necrosis  of  the  jaws  some 
form  of  periostitis  is  the  starting-point  of  the  trouble. 

The  jaws  are  specially  liable  to  necrosis,  consequent  upon 
inflammation,  but  there  is  a  difference  in  the  frequency  with 
which  the  upper  and  lower  jaw  is  attacked.  According  to 
Stanley  ("  Diseases  of  the  Bones/'  p.  69)  the  order  of 
frequency  of  necrosis  of  the  bones  of  the  skeleton  is  as 
follows :  Tibia,  femur,  humerus,  flat  cranial  bones,  loiuer 
■jaw,  last  phalanx  of  finger,  clavicle,  ulna,  radius,  fibula, 
scapula,  ufpjpcr  jaw,  pelvic  bones,  sternum,  ribs ;  and  the 
greater  immunity  enjoyed  by  the  upper  as  compared 
with  the  lower  jaw  is  due,  no  doubt,  partly  to  its  less 
exposed  position,  but  more  especially  to  the  fact  that  necrosis 
occurs  less  frequently  in  cancellous  than  in  compact  bone. 
This  difference  is  probably  due  to  the  fact  that  in  cancellous 
bone  the  inflammatory  products  find  an  easier  channel  to 
the  surface  than  in  compact  bone,  and  so  the  injurious  effects 
of  tension  are  prevented.  The  great  difference  in  the 
supply  of  blood  to  the  two  bones  may  also  have  an  influence, 
the  upper  jaw  being  supplied  by  very  numerous  branches  of 
the  internal  maxillary  arteries,  which  inosculate  freely  from 
side  to  side,  whilst  the  lower  jaw  is  supplied  by  two  small 
branches  only,  which  do  not  anastomose. 

Necrosis  of  the  jaws  will  vary  according  to  the  extent. 


104  NECROSIS    OF    THE   JAWS. 

situation,  and  nature  of  tlie  previous  inflammatory  trouble, 
which,  as  we  have  seen,  is  usually  a  periostitis.  It  will  be 
convenient,  therefore,  to  classify  the  varieties  of  necrosis 
according  to  the  cause. 

1.  Necrosis    of   the  alveolus,  the  inflammation    com- 

mencing in  the  alveolo-dental  periosteum. 

2.  The    inflammation  may  spread  from    the    alveolar 

periosteum  to  the  proper  periosteum  of  the  jaw,  and 
cause  a  more  or  less  extensive  necrosis  of  the  jaw. 

3.  Necrosis    resulting    from  inflammation  around    an 

impacted  wisdom  tooth. 

4.  Syphilitic  necrosis. 

5.  Necrosis  following  the    administration    of    certain 

drugs,  especially  mercury. 

6.  Phosphorus -necrosis. 

7.  Necrosis  occurring  during  the  course  of  certain  acute 

specific  fevers.      (Exanthematous  necrosis.) 

8.  Necrosis  following  injuries  to  the  jaws. 

9.  Necrosis  secondary  to  ulceration  of  the  mouth. 
10.  Necrosis  without  apparent  cause. 

I.  Necrosis  of  the  Alveolus. — We  have  already  seen  that 
the  septic  matter  in  the  carious  focus  of  a  decaying  tooth 
may  reach  the  alveolo-dental  periosteum  and  set  up  acute 
inflammation  there.  In  many  cases  an  alveolar  abscess 
results,  and  this,  if  not  treated  properly,  may  cause  consider- 
able necrosis  of  the  alveolar  portion  of  the  jaw.  Without 
the  formation  of  an  abscess,  however,  the  inflammation  of 
the  dental  periosteum  may  spread  to  the  alveolus  and  lead 
to  the  death  of  the  bone.  This  necrosis  may  be  limited  to 
one  tooth  socket,  or  may  involve  the  sockets  of  several,  or 
even  of  all  the  teeth.  In  the  latter  case  the  trouble  prob- 
ably originates  in  a  general  diffused  alveolar  periostitis, 
which  rapidly  spreads  to  the  bone  and  causes  necrosis  of  the 
alveolar  process. 

Sometimes  one  or  more  of  the  tooth  sockets  may  become 
necrosed  without  any  sign  of  preceding  acute  inflammation. 
Thus,  Garretson,  in  his  "  System  of  Oral  Surgery,"  mentions 
the  case  of  a  man  who  had  gradually  increasing  pain  in  the 


SYPHILITIC    NECROSIS.  105 

lower  jaw,  followed  by  exfoliation  of  two  incisor  teeth  with 
their  bony  sockets.  There  was  no  indication  of  decay  in  the 
teeth  or  of  any  previous  acute  intiammation  of  the  dental 
periosteum. 

Necrosis  of  the  alveolus  is  sometimes  caused  Ijy  the  in- 
cautious use,  on  the  part  of  the  dentist,  of  caustics  for 
destroying  the  pulp  of  a  tooth.  Thus,  after  the  employment 
of  arsenic  for  this  purpose,  a  necrosis,  generally  slight  in 
extent,  of  the  alveolar  margin  may  follow. 

2.  The  destructive  effects  of  inflammation  of  the  alveolar 
periosteum  caused  by  decayed  teeth  may  not  be  limited  to 
the  alveolar  portion  of  the  bone.  The  periosteum  of  the 
jaw  itself  may  become  affected  and  pus  may  spread  widely 
between  the  periosteum  and  the  bone,  leading  to  more  or 
less  necrosis  of  the  body  or  even  ramus  of  the  lower  jaw. 
In  the  case  of  the  upper  jaw  this  destructive  effect  is  but 
seldom  seen  as  a  consequence  of  decayed  teeth.  ' 

3.  Necrosis  caused  by  an  impacted  wisdom  tooth  is  by 
no  means  uncommon,  and  nearly  always  occurs  in  the  lower 
jaw.  Owing  to  the  close  approximation  of  the  second  molar 
tooth  to  the  ramus  of  the  jaw  the  eruption  of  the  wisdom 
teeth  is  prevented.  This  impeded  eruption  often  gives  rise 
to  various  and  apparently  anomalous  symptoms,  which  will 
be  considered  later  (see  Closure).  The  most  serious  result, 
however,  is  the  formation  of  abscesses,  which  burrow  widely 
about  the  angle  of  the  jaws  and  teeth,  leading  to  great 
scarring  and  permanent  deformity.  In  a  young  lady,  seen 
by  me  in  consultation  some  years  ago,  the  mischief  resulting 
from  an  impacted  wisdom  tooth  was  sufficient  to  put  her 
life  in  some  jeopardy,  and  has  left  her  face  permanently 
scarred  by  the  extensive  abscesses. 

4.  Syphilitic  -poison  frequently  produces  necrosis  of  the 
jaws  ;  and  here  we  find  the  observation  of  Stanley  hold  good 
as  in  other  parts  of  the  body.  He  says  (p.  76)  :  "  Syphilis 
produces  its  effects  mostly  upon  the  compact  osseous  textures, 
and  in  portions  of  bones  which  have  thin  soft  coverings,  as 
the  fiat  cranial  bones ; "'  and  it  is  in  the  compact  tissue  of 
the  palatine  plate  of  the  superior  maxilla,  which  is  thinly 


106  NECROSIS    OF    THE    JAWS, 

covered  by  mucous  membrane,  that  we  find  the  ravages  of 
syphilis  most  frequent.  Occasionally  the  disease  leads  to 
necrosis  of  portions  of  the  compact  tissue  of  the  lower  jaw, 
or  attacks  the  alveolus  or  body  of  the  upper  jaw.  Of  this  I 
have  lately  had  two  examples  under  my  own  care,  one  in  a 
medical  man,  from  whom  I  extracted  a  large  piece  of  necrosed 
alveolus,  and  the  other  in  a  discharged  soldier,  aged  twenty- 
three,  in  whom  also  there  was  extensive  necrosis  of  the 
alveolus,  extending  from  the  lateral  incisor  to  the  first 
molar  on  the  right  side.  There  was  no  question  as  to  the 
cause  of  the  disease  in  either  case.  In  cases  of  extensive 
tertiary  ulceration  of  the  face  also,  the  bones  may  become 
secondarily  affected. 

The  question  of  the  influence  of  syphilis  in  producing"^ 
necrosis  of  the  alveolus,  derives  additional  interest  from 
the  recent  trial  of  an  action  against  a  dentist  for  damage 
due  to  necrosis,  said  to  liave  been  caused  by  the  unskilful 
extraction  of  a  tooth  some  months  before.  In  this  case  one 
surgeon  swore  that  necrosis  of  the  jaw  from  syphilis  was 
unknown,  whilst  the  opposite  view  was  strongly  maintained 
by  surgeons  of  great  experience  in  syphilitic  diseases  {British 
Ifcdical  Journal,  August,  1 8  7 1 ). 

The  proper  local  treatment  of  any  ulceration  or  necrosis 
of  the  palate  is  to  protect  the  part  from  contact  of  the 
tongue  and  food,  and  to  close  the  aperture  by  a  properly  fitting 
plate  of  metal  or  vulcanite,  attached  to  the  teeth  and  arching 
immediately  below  the  palate,  without  making  pressure  upon 
the  edges  of  the  hole  itself.  A  caution  may  be  given  against 
any  attempt  on  the  part  of  the  sui'geon  or  patient  to  fill 
the  gap  in  the  roof  of  the  mouth  by  any  form  of  plug  fitting 
into  the  hole  left,  the  effect  of  which  is  to  enlarge  the 
aperture  by  absorption,  so  that  the  size  of  the  plug  has  to  be 
constantly  increased  in  order  to  make  it  effectual.  A 
preparation  in  St.  Bartholomew's  Museum  shows  the  extent  to 
which  this  absorption  may  be  carried  in  process  of  years. 
The  following  is  the  description  given  in  the  Museum 
Catalogue : 

"The    base    of    a    skull    from    an   elderly   woman,  who 


MERCUEIAL   NECEOSIS.  107 

appeared  to  have  been  long  in  tlie  habit  of  wearing  a  plug  to 
close  an  opening  in  the  palate.  The  opening  gradually 
enlarging,  attained  such  a  size  that  nothing  remains  of  the 
palatine  portions  of  the  superior  maxillary  and  palate  bones, 
and  the  alveolar  border  of  the  jaw  is  reduced  to  a  very  thin 
plate,  without  any  trace  of  the  sockets  of  the  teeth.  The 
antrum  is  on  both  sides  obliterated  by  the  apposition  of  its 
walls,  its  inner  wall  having  probably  been  pushed  outwards 
as  the  plug  was  enlarged  to  fit  the  enlarging  aperture  in 
the  palate.  Nearly  the  whole  of  the  vomer  also  has  been 
destroyed,  and  the  superior  ethmoidal  cells  are  laid  open. 
The  plug  is  preserved ;  it  is  composed  of  a  large  circular 
cork,  with  tape  wound  round  it,  and  measures  an  inch  and 
three-quarters  in  diameter,  and  an  inch  in  depth.  The 
history  of  the  patient  is  unknown.  She  was  brought  from  a 
workhouse  to  the  dissecting  rooms,  with  the  plug  tightly  and 
smoothly  fitted  in  the  roof  of  the  mouth  "  (St.  Bartliolomcid' s 
Catalogue,  14). 

Even  the  employment  of  a  piece  of  softened  gutta-percha 
is  not  unattended  with  risk :  thus,  several  years  ago  I  saw, 
with  Mr.  Lawson,  a  case  in  which  a  patient  had  thrust  a 
considerable  quantity  of  softened  gutta-percha  through  an 
aperture  in  the  palate  into  the  nostril,  where  it  formed  a 
hard  mass,  which  was  extracted  only  with  the  greatest 
difficulty  and  at  the  expense  of  tearing  one  of  the 
alfc. 

5.  Mercurial  Necrosis. — The  severe  form  of  mercurial 
necrosis,  of  which  patients  suffering  from  syphilis  were 
mostly  the  victims  in  the  days  when  salivation  was  looked 
upon  as  a  necessary  part  of  the  treatment,  is  now  practically 
unknown.  It  was  formerly  met  with  also  as  a  result  of  the 
destructive  ptyalism  produced  by  the  fumes  of  liquid 
mercury  employed  in  the  manufacture  of  looking-glasses. 
When  glass  plates  were  converted  into  mirrors  by  sliding 
and  compressing  them  on  to  sheets  of  tin-foil  covered  with 
pure  quicksilver,  the  men  employed  were  liable  to  have  their 
teeth  drop  out,  and  frequently  lost  portions  of  the  jaws,  their 
lives  being  notoriously  shortened.     Since  the  introduction  of 


108  NECEOSIS    OF    THE  JAWS. 

a  chemical  process  by  which  the  niercury  is  deposited  on  the 
glass,  these  cases  of  induced  necrosis  have  become  almost 
unknown. 

One  of  the  earliest  symptoms  is  a  metallic  taste,  which  is 
rapidly  succeeded  by  an  inflammation  of  the  mucous 
membrane  of  the  mouth.  The  tongue  becomes  slightly 
swollen,  tooth-indented  and  sore.  The  affection  of  the  gums 
is  very  characteristic.  They  become  swollen,  at  first  around 
the  necks  of  the  teeth,  and  feel  very  sore.  The  inflamma- 
tion spreads  to  the  alveolo-dental  periosteum,  and  the 
effusion  poured  out  raises  the  teeth  from  their  sockets  and 
at  the  same  time  loosens  them.  If  the  disease  is  allowed  to 
progress,  the  alveolar  process  becomes  affected  and  may 
ultimately  become  necrosed.  A  good  example  of  this  is 
seen  in  a  specimen  presented  by  Mr.  Key  to  G-uy's  Hospital 
Museum.  It  is  a  sequestrum  consisting  of  two-thirds  of  the 
alveolar  processes  of  the  lower  jaw,  the  disease  having  been 
induced  by  the  use  of  mercury  for  ovarian  dropsy. 

A  specimen  in  the  museum  of  the  Dublin  College  of 
Surgeons,  showing  exfoliation  of  the  entire  alveolus,  was  also 
due  to  the  administration  of  mercury. 

The  ravages  produced  by  niercury  may  not  be  limited 
to  the  alveolar  process,  but  may  spread  to  any  part  of  the  jaw. 
Thus,  in  the  American  Medical  Times  of  February  23,  1861, 
Dr.  E.  S.  Cooper  records  the  case  of  a  child,  aged  seven,  in 
whom  necrosis  involving  the  left  half  of  the  lower  javv', 
including  coronoid  and  condyloid  processes,  had  been  pro- 
duced by  the  administration  of  calomel.  After  removal 
of  the  sequestrum,  reproduction  of  the  jaw  took  place, 
the  reproduced  bone  being  at  first  very  much  larger 
than  the  natural  bone,  but  gradually  improving  in 
shape. 

Mr.  Stanley  mentions  (p.  72),  and  gives  a  drawing  of  a 
sequestrum  preserved  in  St.  Bartholomew's  Museum  (i,  102), 
embracing  nearly  the  whole  body  of  the  lower  jaw,  which 
suffered  necrosis  after  the  administration  of  a  few  grains  of 
calomel  in  a  case  of  fever.  It  might  be  doubted  whether  the 
necrosis  was  not  due  as  much  to  the  fever  as  to  the  calomel 


PHOSPHORUS-NECROSIS.  1  Of> 

in  this  case,  but  that  Mr.  Stanley  mentions  that  the  patient 
had  excessi\-e  salivation  and  severe  inflammation  in  the  gums 
and  cheeks. 

Drugs,  other  than  mercury,  producing  profuse  salivation, 
may  lead  to  trouble  in  the  dental  periosteum,  but  in  these 
cases  necrosis  very  rarely  follows. 

6.  P]iOs'pJio7'us-Necrosis. — This,  which  is  perhaps  the  most 
formidable  kind  of  necrosis  of  tlie  jaw,  is  a  disease  of 
modern  time,  having  been  called  into  existence  only  since 
the  introduction  of  lucifer-matches,  into  the  inflammable 
material  of  which  phosphorus  largely  enters.  The  earliest 
mention  by  British  writers  of  disease  in  connection  with  the 
manufacture  of  lucifers,  appears  to  have  been  by  Dr.  Wilks, 
in  the  Guys  Hospital  Reports  of  1846-47;  but  a  paragraph 
from  a  German  author  upon  the  subject  is  quoted  in  the 
Lancet  of  August  29,  1846.  The  notice  in  the  G-uy's 
Hospital  Eeports  is  of  a  case  of  disease  of  the  lower  jaw  witli 
exfoliation,  occurring  in  a  lucifer-match  maker ;  and  the 
remark  is  made  that  the  disease  had  been  noticed  to  be 
common  among  workers  in  lucifer  manufactories — a  branch 
of  industry  which  had  then  been  introduced  into  London 
some  ten  years.  In  Germany,  howe^'er  (where  lucifer 
manufactories  were  started  some  years  earlier  than  in 
England),  phosphorus-necrosis  was  recognised  as  early  as 
1839  by  Lorinser,  who  published  a  paper  upon  the  subject 
in  1845,  and  was  followed  by  Strohl,  Hey f elder,  Eoussel, 
and  Gendrin,  and  by  Sedillot  in  1846.  In  1847  Drs.  Von 
Bibra  and  Geist,  of  Erlangen,  published  a  work  {Die 
Krankhciteii  cler  Arheiter  in  den  Fhosphorzitnelholzfahnlcen, 
inshcsondcre  das  Leiden  der  Kieferknochen  durch  PliosplLOv- 
ddmpfe),  which  forms  the  basis  of  our  present  knowledge  of 
the  subject,  and  the  conclusions  of  which  further  experience 
has  fully  confirmed. 

In  London,  the  lucifer  manufactories  being  principally  at 
the  East  End,  cases  of  phosphorus-necrosis  are  most  common 
in  St.  Bartholomew's,  the  London,  and  the  Borough  hospitals  ; 
and  their  museums,  especially  that  of  St.  Bartholomew's,  are 
very    rich    in    specimens.      The    medical    officers    of    these 


110  NECROSIS    OF    THE    JAWS. 

institutions  having  thus  had  special  opportunities  of  study, 
have  not  failed  to  record  their  experience,  and  reference 
may  be  made  to  valuable  clinical  lectures  upon  the  subject 
by  Mr.  Simon  {Lancet,  1850),  Sir  J.  Paget  {Medical  Times 
and  Gazette,  1862);  and  Mr.  Adams  {Mcdiccd  Times  and 
Gazette,  1863);  and  to  the  essay  on  Surgical  Diseases 
connected  with  the  Teeth,  by  Mr.  J.  Salter  ("  System  of 
Surgery,"  vol.  ii). 

Etiology. — The  cause  of  the  disease  is,  unquestionably,  the 
fumes  of  the  phosphorus  which  are  inhaled  by  the  operatives 
during  the  process  of  "dipping"  the  matches, and  in  a  lesser 
■degree  during  the  counting  and  packing  them.  When  the 
disease  first  showed  itself  in  Germany,  it  was  thought  that 
it  depended  upon  the  admixture  of  arsenic  with  the 
phosphorus ;  and  it  is  curious  that  in  the  Museum  of  St. 
Bartholomew's  there  are  some  bones  of  cows  from  the 
neighbourhood  of  Swansea,  which,  under  the  influence  of 
arsenical  vapour,  have  become  enlarged  and  covered  with  a 
new  bone  formation  closely  resembling  that  around  phos- 
phorus-necrosis. It  has  been  proved,  however,  that  arsenic 
has  nothing  to  do  with  the  disease ;  and  if  proof  positive 
were  wanting  that  phosphorus  alone  is  the  deleterious  agent, 
it  is  supplied  by  a  case  quoted  by  Sir  J.  Paget,  in  the  lecture 
referred  to,  of  a  man  who  induced  necrosis  of  his  jaws  by 
inhaling  fumes  of  phosphoric  acid  as  a  quack  remedy  for 
■"  nervousness." 

Lorinser  and  the  earlier  writers  considered  the  disease  to 
■consist  in  blood-poisoning,  the  necrosis  of  the  jaw  being 
consequent  thereupon,  and  Mr.  Adams  (loc.  cit.)  thinks  that 
the  theory  of  blood-poisoning  should  not  be  altogether 
discarded,  since  the  local  disease  would  not  account  for  the 
constitutional  symptoms  experienced.  This  view  has  recently 
received  the  support  of  the  eminent  Berlin  surgeon  Von 
Langenbeck,  who  maintains  that  all  the  general  symptoms 
of  phosphorus-poisoning  are  present  long  before  the  local 
disease,  which  he  calls  periostitis  rather  than  necrosis, 
manifests  itself  {Berliner  Klinischc  WochenscJirift,  Jan.  8  th, 
1872).     The  majority  of  surgeons  agree,  however,  in  con- 


]'II0S1'H0EUS-NECK0S1S.  Ill 

sidering  the  affection  essentially  a  local  one,  the  constitutional 
symptoms  being  only  consecutive,  and  an  interesting  account 
of  the  post-mortem  examination  of  a  case  of  general 
poisoning  by  phosphorus,  following  necrosis  of  the  jaw,  will 
be  found  in  the  Fatliohnjlcal  Society  s  Transactions  for  1869. 

It  is  found  that  the  phosphorus  fumes  produce  no  in- 
jurious effects  so  long  as  the  teeth  and  gums  of  the  workers 
are  sound,  but  as  soon  as  the  teeth  become  carious,  or  if  a 
tooth  is  extracted  so  as  to  leave  an  open  socket,  the  disease 
rapidly  develops  itself.  The  experiments  upon  animals,  by 
Geist  and  Von  Bibra,  are  amply  confirmatory  of  this  view, 
since  they  found  that  rabbits  exposed  to  phosphoric  fumes 
suffered  no  injury  so  long  as  the  teeth  and  jaws  were  unin- 
jured, but  that  if  the  teeth  were  extracted  or  the  jaw  broken, 
periostitis  and  necrosis  rapidly  resulted.  On  the  other  hand, 
it  may  be  mentioned  that  a  case  has  been  recorded  by  Grran- 
didier  {Journal  fur  Kindcrhranlilidtcn,  1861),  of  necrosis 
of  the  upper  jaw  from  phosphorus  fumes  in  a  child  but  six 
weeks  old,  and  in  whom  therefore  the  teeth  were  not  de- 
veloped ;  and  Langenbeck  is  opposed  to  the  notion  that 
carious  teeth  predispose  to  the  disorder. 

The  liability  of  the  two  jaws  to  the  disease  appears  to  be 
about  the  same,  or  perhaps  with  a  slight  preponderance  in 
favour  of  the  lower  jaw.  Of  52  cases  given  by  German 
authorities,  2 1  were  of  the  superior  maxilla,  2  5  of  the  in- 
ferior maxilla  ;  in  5  both  jaws  were  involved,  and  one  case 
is  uncertain  {British  and  Foreign  Medico-Chirurgical  Bevicu-, 
April,  1848).  Mr.  Salter  {loc.  cit.)  says:  "In  five  cases 
which  I  have  witnessed,  the  lower  jaw  was  diseased  in  four, 
and  the  upper  in  one ;  whereas  four  which  occurred  in  the 
practice  of  a  surgical  friend  were  confined  to  the  upper  jaw. 
In  seventeen  instances  of  which  I  have  obtained  particulars 
or  seen  specimens,  nine  were  connected  with  the  superior, 
and  eight  with  the  inferior  maxilla.  The  disease  is  there- 
fore pretty  evenly  balanced  between  the  two  jaws."  The 
St.  Bartholomew's  Hospital  Museum  contains  excellent 
specimens  of  both  jaws  affected  by  this  form  of  disease. 

Symptoms. — As  the   disease   commences  in  the  alveolo- 


112  NECEOSIS    OF  THE    JAWS. 

dental  periosteum,  the  early  symptoms  are  those  of  alveolar 
periostitis  (see  p.  91). 

Pain  referred  to  the  teeth  is  one  of  the  earliest  symptoms 
of  the  disease,  and  this,  which  was  intermittent  at  first, 
becomes  at  length  continuous.  The  teeth  become  loose,  and 
pus  is  seen  to  exude  from  their  sockets.  At  the  same  time 
the  gums  become  swollen  and  tender,  and  are  detached  to  a 
greater  or  lesser  degree  from  the  alveoli,  giving  constant  exit 
to  a  purulent  discharge.  In  many  cases  of  necrosis  the  face 
is  swollen,  so  that,  if  only  one  side  of  the  jaw  is  affected,  a 
peculiar  lop-sided  effect  is  produced.  In  the  cases  of 
phosphorus-necrosis,  however,  the  swelling  of  the  face .  is 
much  more  marked,  the  soft  tissues  around  the  bone  being 
infiltrated  and  puffy  to  an  extent  which  is  not  witnessed  in 
other  forms  of  the  disease.  One  or  more  openings  now 
form  externally,  through  which  pus  constantly  exudes,  and 
the  probe,  introduced  through  these,  readily  reaches  bare 
and  dead  bone. 

The  patient's  general  health  has  by  this  time  become 
seriously  affected,  owing  both  to  the  actual  suffering  he  has 
undergone,  and  to  the  interference  with  his  nutrition  which 
the  state  of  his  mouth  necessarily  involves  ;  it  being  im- 
possible for  him  to  take  any  but  fluid  or  semi-fluid  food, 
and  that  in  small  quantities.  The  constant  presence  of 
most  offensive  discharges  in  the  mouth,  and  mixing  with  the 
food,  must  have  an  injurious  effect  upon  the  patient,  though 
this  is  questioned  by  Salter,  who  remarks  that  these  patients 
swallow  daily  many  ounces  of  pus  "  without  any  obvious 
detriment  to  health."  The  necrosed  portions  of  bone  pro- 
ject more  or  less  into  the  mouth,  and  give  the  patient  great 
inconvenience,  and  in  very  severe  cases  of  phosphorus- 
necrosis  gangrene  of  the  cheeks  and  lips  ensues,  with  a 
rapidly  fatal  termination.  In  less  severe  cases,  the  patient 
may  drag  on  a  wretched  existence  for  months,  and  sink  at 
last  from  exhaustion^  or  may  occasionally  recover  with  con- 
siderable loss  of  bone  and  deformity. 

Advanced  necrosis  of  the  upper  jaw  may  lead  to  exten- 
sion of  mischief  to  the  brain  with  a  fatal  result,  as  I  have 


EXANTHEMATOUS    NECROSIS. 


113 


myself  seen  on  one  occasion.  The  patient  was  a  young- 
woman,  aged  twenty-three,  in  whom  necrosis  of  the  upper 
jaw  had  existed  for  nine  months,  when  head  symptoms 
supervened,  and  she  rapidly  sank  and  died  comatose.  At 
the  post-mortem  examination  I  found  an  abscess  in  the 
anterior  lobe  of  the  cerebrum,  evidently  originating  from 
the  ethmoid  bone,  the  cribriform  plate  of  which  was  necrosed 
and  perforated. 

7.  Mxanthematous  Necrosis. — Under  this  name,  Mr.  Salter 
has  described  {G-uys  Hospital  Beports,  vol.  iv,  and  System  of 
Surgery,  vol.  ii)  the  form  of  necrosis  of  the  jaw  in   children 

Fig.  42. 


A,  anterior  ;  b,  external ;  c,  internal  view  of  inter-maxillary  bones. 

which  depends  upon  the  poisonous  effects  of  some  of  the 
exanthematous  diseases,  and  especially  scarlet  fever.  Mr. 
Salter  claims  to  have  been  the  first  to  call  attention  to  this 
form  of  necrosis  and  to  trace  it  to  its  cause,  and  has  met 
with  over  twenty  instances  of  the  affection.  In  the  Patlio- 
Jogical  Society  s  Transactions  (vol.  xi),  he  has  described  and 
figured  seven  specimens  of  the  exfoliation — four  after 
scarlet  fever,  two  after  measles,  and  one  after  small-pox. 
The  disease  appears  to  occur  most  frequently  about  the  age 
of  five  or  six  years,  when  each  jaw  contains  the  whole  of  the 
first  set,  and  the  germs  more  or  less  advanced  of  the  second 
set  of  teeth  ;  but  Mr.  Bryant  has  recorded  (PatJiological  Soc. 
Trans.,  vol.  x)  a  case  of  exfoliation  of  the  intermaxillary 
bones  after  measles  in  a  child  of  three  (Fig.  42)   and  the 

H 


114  NECROSIS    OF    THE    JAAVS. 

boy  Barton  Blackmail,  already  referred  to,  is  an  instance  of 
the  kind,  at  the  age  of  ten. 

The  disease  first  shows  itself,  a  few  weeks  after  the  occur- 
rence of  the  feverish  attack,  in  tenderness  of  the  month  and 
foetor  of  the  breath,  and  the  gum  is  seen  to  be  separated 
from  the  teeth  and  alveolus.  The  inflammation  really 
commences  in  the  alveolar  periosteum  and  is  remarkably 
symmetrical,  appearing  almost  simultaneously  on  both  sides 
of  the  jaw,  and  rapidly  denuding  the  bone,  thus  leading  to 
necrosis  and  subsequent  exfoliation  of  considerable  portions 
of  it.  These  usually  include  the  whole  depth  of  the 
alveolus,  together  with  the  partially-developed  permanent 
teeth;  but  no  case  has  been  met  with  in  which  the  lower 
border  of  the  jaw  was  involved. 

It  is  possible  that  this  disorder  might  be  confounded  with 
cancrmn  oris  in  its  early  stage,  but  the  absence  of  ulceration 
of  the  gum  would  at  once  distinguish  it. 

I  am  indebted  to  Mr.  N.  Tracy,  of  Ipswich,  for  a  prepara- 
tion of  necrosis  following  scarlet  fever,  in  a  girl  of  thirteen, 
which  is  preserved  in  the  College  of  Surgeons  Museum. 
The  disease  was,  as  usual,  symmetrical,  but  the  right 
side  was  more  deeply  involved  than  the  left.  On  the 
right  side  the  sequestrum,  if  inch  in  length,  and  f  inch  in 
depth,  contained  the  permanent  first  molar  and  the  uncut 
permanent  bicuspid  teeth,  besides  a  temporary  molar  ;  and 
involved  part  of  the  socket  of  the  second  permanent  molar 
behind,  and  of  the  canine  in  front.  On  the  left  side  the 
disease  involved  only  a  portion  of  the  alveolar  border,  in- 
cluding a  temporary  molar  tooth.  A  model,  taken  three 
years  later,  showed  the  permanent  gap  left  between  the 
canine  and  the  first  molar  teeth  on  the  right  side. 

A  very  remarkable  extensive  necrosis  of  the  lower  jaw, 
occurring  in  a  child  of  four,  is  shown  in  Eig.  43,  taken,  by 
permission,  from  a  specimen  brought  before  the  Pathological 
Society  by  Mr.  Waren  Tay  (Pathological  Soc.  Trans.,  1874). 
The  sequestrum  includes  the  whole  lower  jaw,  with  the 
exception  of  one  condyle,  and  the  subsequent  repair  seems  to 
have  been  very  complete.     The  cause  of  the  mischief  appears 


EXANTHEMATOUS    XECllOSIS. 


115 


to  have  been  doubtful,  but  may  have  been  due  to  the  trick 
of  sucking  lucifer-matches,  in  which  the  child  is  said  to  have 
indulged.  Mr.  Tay  brought  this  patient  again  before  the 
Pathological  Society  in  November,  1883,  when  there  was  a 
firm  ring  of  new  bone  present  in  the  situation  of  the  jaw, 
quite  strong  enough  to  give  support  to  artificial  teeth  if  they 
were  supplied.  At  the  posterior  part  of  the  left  side  a  sharp- 
■edged  tooth  has  made  its  appearance  lately.  He  could 
depress  and  elevate  the  jaw  vigorously.     On  the  left  side. 

Fig.  43. 


where  the  condyle  was  wholly  removed,  there  was  good 
lateral  movement,  but  on  the  right  side,  the  movements  were 
not  so  free,  though  he  had  no  difficulty  in  chewing  food. 

Mr.  Salter  regards  necrosis  after  typhoid  fever  as  of  rare 
occurrence.  In  the  Guy's  Hospital  Museum,  however,  is  a 
portion  of  lower  jaw,  consisting  of  condyle,  angle,  and  part 
of  the  body  of  the  bone,  separated  by  necrosis  after  fever, 
from  a  boy  of  fourteen.  He  recovered  with  comparatively 
trifling  deformity,  and  the  skin  remained  sensitive,  although 
a  large  part  of  the  trunk  of  the  nerve  must  have  been 
destroyed.  In  St.  George's  Hospital  Museum  also  there 
are  specimens  of  necrosis  of  the  lower    jaw  and  clavicle 


116  XECEOSIS    OF    THE    JAWS, 

in  fever,  A  case  of  very  extensive  necrosis  occurring 
after  fever,  under  Mr,  Stanley's  care,  will  be  referred  to 
further  on. 

8.  Necrosis  follov/bng  Injuries. — In  the  chapter  on  compli- 
cations of  fracture  of  the  jaws,  attention  has  been  drawn  to 
the  necrosis  that  may  follow,  especially  after  injuries  caused 
by  firearms.  The  unskilful  extraction  of  a  tooth  may  lead 
to  fracture  of  more  or  less  of  the  alveolar  margin,  followed  by 
necrosis,  and,  according  to  Tomes,  "  necrosis  of  a  portion  of 
the  bone  may  follow  upon  the  extraction  of  a  tooth,  how- 
ever skilfully  this  has  been  performed  ;  and  it  must  not  be 
supposed  that  the  operator  is  always,  or  even  commonly, 
to  blame  for  the  advent  of  necrosis  after  the  extraction  of  a 
tooth.  The  conditions  leading  to  necrosis  are,  in  the  great 
majority  of  cases,  developed  previously  to  the  removal  of  the 
tooth,  and  are  quite  independent  of  its  removal ;  the  necrosis 
would  generally  have  been  quite  as  sure,  and  perhaps  even 
more  extensive,  had  the  tooth  been  left  in." 

9.  Necrosis  secondary  to  Ulceration  of  the  Mouth. — In 
cases  of  cancrum  oris  it  is  by  no  means  uncommon  to  find 
a  more  or  less  extensive  necrosis  of  the  jaw.  The  acute 
spreading  inflammation  may  rapidly  involve  the  periosteum 
of  either  or  even  of  both  jaws,  and  lead  to  necrosis.  It  is 
very  rarely  indeed  that  these  cases  recover.  If  they  do, 
there  is  nearly  always  considerable  deformity  of  the  face 
and  interference  with  the  movements  of  the  lower  jaw. 

Again,  necrosis  may  be  secondary  to  ulceration  of  the 
mouth,  met  with  in  patients  suffering  from  scurvy.  Occa- 
sionally ulcerating  growths  of  the  face  or  jaws  may  lead  to 
necrosis  of  the  jaws. 

10.  Necrosis  loitlwut  any  Apparent  Cause. — Slight 
necrosis,  limited  to  a  tooth  socket,  occurring  without  any 
apparent  cause,  has  already  been  alluded  to  (see  p.  104). 
Much  more  extensive  necrosis  than  this  may  occur,  however. 
Thus,  Stanley  mentions  the  case  of  a  man,  aged  thirty,  who, 
twelve  months  before  he  saw  him,  began  to  suffer  pain  in 
his  upper  jaw,  soon  after  which  the  teeth  fell  out  of  their 
sockets  and  matter  was  discharged  into  the  mouth.     When 


NECROSIS    WITHOUT   APPARENT    CAUSE. 


117 


the  dead  bone  was  sufficiently  loosened  Mr.  Stanley  drew 
away  the  greater  ijart  of  both  superior  maxilhe. 

Avery  similar  case  occurring  in  a  strumous  man,  aged 
forty,  is  recorded  by  ]\Ir.  Ernest  Hart,  in  the  Lamet, 
July  iQtli,  1862,  and  by  the  kindness  of  that  gentleman 
I  am  enabled  to  reproduce  the  drawings  of  the  bones  when 
removed,  and  of  the  patient  after  the  operation. 

A  second  case,  very  similar  to  the  above  as  respects  the 
absence  of  cause  for  the  disease,  has  been  recently  under  my 
notice,  the  report  of  it  having  been  Icindly  furnished  to  me 


Fig.  44. 


FK4.  45. 


by  Dr.  Garnham,  of  the  Peninsular  and  Oriental  Company's 
Service.  The  patient,  aged  forty,  was  an  engineer  in  the 
Company's  service,  and  enjoyed  perfectly  good  health  in  the 
tropics  for  some  years,  but  soon  after  his  return  to  England 
his  mouth  became  sore,  sloughing  of  the  gums  took  place, 
and,  when  I  first  saw  him,  very  large  portions  of  the 
alveolus  of  the  lower  jaw  were  necrosed,  and  lying  exposed 
in  the  mouth.  Subsequently  these  came  away  or  were 
removed  by  Dr.  Garnham,  and  the  patient  having  been 
reduced  to  an  edentulous  condition,  as  regards  the  lower 
jaw,  it  became  necessary  to  apply  to  Mr.  C.  J.  Eox,  the 
dentist,  for  artificial  aid.  Dr.  Garnham  attributes  the  disease 
to  depression  of  the  vital  powers,  owing  to  long  residence  in 
warm  climates. 


CHAPTEE  IX. 

EEPAIE  AFTER  NECEOSIS. — TREATMENT  OF  NECROSIS. 

There  is  a  striking  difference  in  the  amount  of  repair 
that  takes  place  after  necrosis  of  the  whole  or  portions  of 
the  upper  and  lower  jaws.  In  the  latter  case  the  periosteum 
is  very  active  in  producing  new  bone,  to  take  the  place 
eventually  of  that  which  is  necrosed.  In  the  case  of  the 
upper  jaw,  however,  there  is  only  a  slight  tendency  for  repair 
to  take  place. 

Upper  Jcni-. — In  adult  life,  except  in  rare  instances,  the 
periosteum  of  the  upper  jaw  makes  no  effort  at  repairing: 
the  mischief  which  has  taken  place.  M,  Oilier,  of  Lyons,  in 
his  very  valuable  work  La  Bdgdncrcdion  dcs  Os,  1867,  giveS' 
a  case  of  phosphorus-necrosis  of  the  upper  jaws  where  a 
certain  amount  of  new  bone  was  produced,  and  also  one  of 
necrosis  of  the  upper  jaw  from  other  causes  in  which  a 
development  of  osteo-fibrous  tissue  took  place  in  a  young 
woman  of  nineteen.  He  quotes  also  from  the  practice  of 
Billroth,  of  Zurich,  the  case  of  a  man,  aged  twenty-seven,  in 
whom,  after  phosphorus-necrosis,  a  development  of  plates  of 
bone  took  place.  These  cases  must  be  regarded,  however,, 
as  quite  exceptional,  Trelat,  in  his  thesis  (1857),  having  failed 
to  discover  a  case  of  osseous  reproduction  of  the  superior 
maxilla.  In  children,  on  the  other  hand,  a  development  of 
tough  fibrous  tissue  takes  place,  which  gradually  fills  up 
pretty  completely  the  cavity  left,  and  thus,  to  a  great  degree,, 
prevents  the  falling  in  of  the  cheek  and  consequent  deformity 
which  would  otherwise  occur.  In  the  Museum  of  King's 
College  is  a  preparation  of  the  nearly  entire  upper  jaw  of  a 
child,  which  became  necrosed  as  a  consequence  of  small-pox, 


RErAIR    AFTER    NECROSIS.  119 

and  was  removed  by  Mr.  Partridge,  when  surgeon  to  the 
Charing  Cross  Hospital.  By  the  kindness  of  the  late  Mr. 
Canton,  I  had  access  to  a  photograph  of  this  patient,  taken 
within  the  last  few  years,  which  shows  the  very  sHght  de- 
formity now  present,  in  consequence  of  this  repair  of  the 
original  mischief. 

This  statement  respecting  the  repair  of  a  necrosed  superior 
maxilla  is,  at  first  sight,  in  opposition  to  the  opinion  of 
Stanley  ("  On  Diseases  of  the  Bones,"  p.  72),  who  says, 
"  under  whatever  circumstances  the  necrosis  has  occurred,  it 
is  not,  as  I  believe,  ever  followed  by  the  slightest  reproduc- 
tion of  the  lost  bone."  This  I  believe  to  be  true  quoad 
the  reproduction  of  actual  bone,  and  in  the  case  of  adults, 
but  the  filling  up  of  the  cavity  by  fibrous  tissue  I  have 
witnessed  in  young  subjects  after  the  removal  of  tumours. 

Lower  Jaw. — The  repair  that  takes  place  after  necrosis  of 
the  entire  or  a  portion  of  the  lower  jaw  may  be  very  com- 
plete.  As  soon  as  the  pus  that  has  formed  has  been  given 
a  free  exit,  and  the  acute  inflammation  has  subsided,  the 
periosteum  begins  to  develop  new  bone,  which  forms  a 
more  or  less  complete  shell  around  the  necrosed  portion. 
Through  the  cloacae,  or  openings,  in  this  new  shell  of  bone, 
which  correspond  to  the  external  apertures  on  the  skin,  and 
also  from  the  mouth,  the  dead  bone  or  scqiiestruin.  can  be 
readily  examined  with  the  probe,  and,  when  sufficiently  de- 
tached and  loosened  to  be  readily  extracted,  it  should  be 
removed  if  possible  through  the  mouth  so  as  to  avoid  de- 
formity from  an  external  wound.  It  is  of  importance  that 
this  removal  should  not  be  undertaken  until  the  shell  of  new 
bone  is  sufficiently  organised  to  maintain  the  shape  of  the 
original  bone,  for  if  otherwise,  the  reproduction  of  the  bone 
will  be  interfered  with,  and  perhaps  prevented.  So  soon  as 
the  sequestrum  is  removed  from  the  interior  of  the  shell  of 
new  bone,  the  space  thus  left  becomes  rapidly  filled  with 
granulations  springing  up  from  the  whole  surface  of  the 
cavity,  and  these  are  soon  converted  into  a  fibrous  mass, 
which  is  ultimately  developed  into  bone.  In  1869  I  had 
under   my  care  in   University   College  Hospital  a  case  of 


120  KEPAIR    AFTER    NECROSIS. 

necrosis  of  nearly  the  entire  lower  jaw  in  a  man  of  twenty- 
two,  from  whose  mouth  I  extracted  several  large  sequestra, 
including  the  right  condyle.  In  this  case,  and  in  others 
of  the  kind  which  I  have  seen,  the  repair  has  been  of 
the  most  perfect  kind,  the  movements  of  the  jaw  being 
as  free  as  if  the  articulation  had  not  been  interfered 
with. 

In  the  Medico-Chirurgical  Trails.^  vol.  Ivii,  is  a  case  of 
phosphorus-necrosis,  reported  by  Sir  W.  Savory,  in  which,  six 
months  before  the  death  of  the  patient,  a  lad  of  eighteen, 
the  whole  of  the  lower  jaw  was  extracted,  and  is  pre- 
served in  St.  Bartholomew's  Museum.  Although  "  at  this 
time  there  was  not  sufficient  firmness  in  any  part  of  the 
region  to  indicate  the  formation  of  new  bone,  yet  in  the 
course  of  a  week  or  two  afterwards  there  was  distinct  evi- 
dence of  new  bone  on  either  side  about  the  angle,  which 
gradually  extended."  The  new  lower  jaw  which  had  been 
formed  is  shown  in  Fig.  46,  and  is  perhaps  one  of  the 
most  perfect  specimens  of  the  kind  ever  seen.  "  In  size, 
shape,  and  development  it  is  very  remarkable.  The  bone 
is  solid  and  dense,  and  in  two  pieces  only.  The  greater 
portion  constitutes  the  whole  of  the  bone,  with  the  excep- 
tion of  the  right  ramus.  This  was  united  to  the  body 
by  fibrous  tissue,  and  separated  during  maceration.  In  size 
and  form,  and  especially  in  the  absence  of  alveolar  por- 
tions, the  jaw  very  nearly  resembles  the  edentulous  maxilla 
of  a  very  old  person,  as  shown  in  Fig.  47." 

In  former  years  there  has  been  a  great  deal  of  discussion 
concerning  the  source  of  this  new  bone.  At  the  present 
day  there  seems  no  doubt  that  the  new  bone  can  only 
be  formed  from  the  periosteum  or  from  any  living  bone 
which  may  remain,  and  that  if  the  former  is  destroyed  by 
the  acute  inflammatory  process  which  caused  the  necrosis, 
no  repair  can  take  place.  In  the  majority  of  instances  the 
periosteum  is  not  completely  destroyed,  but  can  form,  to 
a  greater  or  less  degree,  new  bone. 

Even  when  the  condyle  with  a  large  portion  of  the  ramus 
of  the  jaw  is  necrosed,  complete  repair  has  been  found  in 


REPAIR    AFTER    NECROSIS, 
lie,    46. 


121 


122  KEPAIR    AFTER    NECROSIS. 

young  subjects.  Stanley,  however,  quotes  a  case  of  this 
kind  from  Desault,  as  one  "  of  the  least  frequent  examples 
of  the  reproduction  of  bone  consequent  on  necrosis,"  and  re- 
fers to  one  recorded  by  Mr.  Syme.  As  additional  examples 
may  be  quoted  one  by  the  late  Mr.  H.  Gray  {JPatJwlogical 
Transactions,  vol.  ii),  which  occurred  in  the  practice  of  Mr. 
Keate,  and  one  by  Dr.  Cooper,  of  San  Francisco,  which  has 
been  already  referred  to.  A  case  of  sub-periosteal  resection 
of  one  half  of  the  jaw  by  M.  Maisonneuve,  in  which  com- 
plete repair  took  place,  will  be  referred  to  further  on. 

On  the  other  hand  it  should  be  remarked  that  several  in- 
stances of  non-repair  of  lost  bone  have  been  recorded.  Thus, 
Stanley  mentions  a  case  under  the  care  of  Mr.  Perry,  which 
will  be  referred  to  again,  in  which  no  repair  took  place :  and 
three  similar  cases  are  to  be  found  in  South's  Chelius.  Also 
in  the  Lancet,  January  25th,  1862,  it  is  mentioned 
that  a  patient  from  whom  ]\Ir,  T.  Wakley  removed  an 
extensive  necrosis  in  1857,  was  at  that  time  to  be  seen 
about  the  streets  exhibiting  himself  for  a  livelihood, 
and  everting  his  mouth  to  show  that  his  lower  jaw  was 
absent. 

In  rare  instances  the  alveolar  margin  of  the  bone  has 
escaped  death  although  the  whole  of  the  rest  of  the  jaw  has 
become  completely  necrosed.  Thus,  in  Mr.  Perry's  case, 
mentioned  above,  although  the  entire  jaw  was  necrosed 
and  removed,  "  nearly  all  the  teeth  remained  in  the  mouth 
and  were  kept  together  by  their  connection  with  the 
gum." 

Extraordinary  as  it  appears  that  the  teeth  should  thus 
remain  in  situ,  the  fact  is  undoubted  and  is  confirmed  by 
other  examples :  thus,  Mr.  Sharp,  of  Bradford  {Medico- 
Chirurgical  Transccctions,  vol.  xxvii),  removed  a  large  seques- 
trum from  a  young  woman,  aged  twenty,  through  an  incision 
beneath  the  chin,  and  all  the  teeth  remained  firm.  In  the 
Medical  Times  and  Gazette  of  October  30th,  1858,  also,  it  is 
mentioned  that  Mr.  Skey  brought  before  the  students  of 
St.  Bartholomew's  a  young  man  of  twenty,  from  whom,  four 
months  before,  he  had  removed  a  sequestrum  including  the 


REPAIR    AFTER   NECROSIS,  123 

entire  left  side  of  the  jaw  from  the  ramus  to  the  symphysis, 
and  the  right  side  as  far  as  the  last  molar  tooth.  The 
sequestrum  showed  the  sockets  of  twelve  teeth — viz.,  all 
those  of  the  left  side,  and  the  incisors,  canine,  and  first 
bicuspid  of  the  right  side ;  but  the  whole  of  the  alveolar 
border  of  the  right  side  was  not  present  in  the  sequestrum. 
Instead  of  coming  away  with  the  bone,  the  incisors,  canine, 
and  first  bicuspid  of  the  right  side,  and  even  the  left  central 
incisor,  had  remained  in  the  gum.  The  patient  now  applied 
to  Mr.  Skey  to  have  these  teeth  removed,  as,  although  they 
evidently  possessed  vitality  and  were  firmly  attached  to  the 
gums,  they  had  sunk  in  position  so  as  to  be  irregular  and 
inconvenient.  I  have,  however,  seen  one  case  in  which  the 
teeth  remained  firm  and  useful  after  extensive  necrosis ; 
but  in  this  case  the  sequestrum  involved  only  the  outer 
plate  of  the  jaw,  the  inner  with  a  great  part  of  each  socket 
being  left  for  the  support  of  the  fangs  of  the  teeth. 

An  observation  of  Mr.  Salter's  ("  System  of  Surgery," 
vol.ii)  deserves  notice,  and  it  received  confirmation  from  one  of 
the  cases  recorded  by  Mr.  Chalk  in  the  paper  already  referred 
to.  He  says,  "  Though  it  has  not  been  stated  in  books,  this 
repair  of  the  lower  jaw  is  but  temporary,  for  after  a  time — • 
often  a  considerable  time — the  new  bone  diminishes  by 
absorption  to  a  mere  arch,  and  ultimately  there  is  scarcely 
enough  bone  to  keep  out  the  lower  lip,  and  the  chin  is 
utterly  lost.  I  have  had  an  opportunity  of  examining  this 
state  of  parts  after  the  lower  jaw  had  been  removed  ten 
years.  How  far  this  loss,  by  absorption  of  supplemental 
bone,  may  be  prevented  by  supplying  it  with  a  function 
through  the  means  of  artificial  teeth,  is  a  question  of  theo- 
retical interest  and  of  practical  importance." 

One,  almost  constant,  pathological  peculiarity  in  cases  of 
phosphorus-necrosis  has  been  already  alluded  to,  and  deserves 
special  notice ;  it  is  the  deposit  of  a  peculiar,  pumice-like, 
bony  material  around  the  necrosed  portions  of  the  lower  jaw, 
for  it  is  not  found  in  cases  of  disease  of  the  upper  jaw. 
This  is  doubtless  derived  from  the  periosteum,  although  so 
closely  adherent  to   the    sequestrum    as   to   be   invariably 


124  REPAIR  AFTER    NECROSIS. 

brought  away  with  it ;  and  though  resembling  true  bone  in 
some  particulars,  it  is  decidedly  of  a  lower  development. 

According  to  Von  Bibra  (op.  cit.),  who  has  laboriously 
investigated  the  subject  microscopically,  the  Haversian  canals 
exhibit  in  part  a  larger  diameter  than  those  of  normal  bone 
and  are  empty,  except  where  the  deposit  appears  smooth 
and  compact,  and  is  partially  covered  with  periosteum. 
They  are  not  parallel  with  the  general  direction  of  the  bone, 
but  are  placed  at  right  angles  to  the  latter ;  they  interlace 
with  one  another,  sometimes  expanding  to  form  sacs,  some- 
times contracting,  and  end  with  open  mouths  on  the  surface. 
Their  mouths  are  more  minute  in  the  most  recent  deposit, 
and  appear  larger  in  older  layers.  The  bone  corpuscles  are 
rounded  off  or  angular,  and  their  circumference  is  less 
decided  ;  during  the  progress  of  the  formation  of  the  deposit 
they  are  very  large,  and  their  contour  proportionably  unde- 
fined. They  appear  filled  and  dark-coloured ;  at  first  they 
are  lighter,  and  they  have  ramifications  like  those  of  normal 
bone,  which  increase  in  number  with  the  age  of  the  deposit. 
The  fundamental  structure  of  the  deposit  is  laminated,  and 
several  layers  are  distinctly  seen  resting  upon  one  another. 
It  exhibits  rents  with  which  the  ramifications  of  the  cor- 
puscles are  connected,  and  which  may  therefore  be  con- 
sidered as  continuations  of  the  latter.  Spots  are  also  visible 
here  and  there,  which  Von  Bibra  looks  upon  as  accumulations 
of  earthy  matter.  This  matrix  of  the  new  deposit  is  at  first 
very  brittle ;  after  the  deposit  has  been  exposed  to  the 
process  of  absorption  it  shows  a  powdery  appearance,  as  if 
sprinkled  with  a  coarse  powder. 

It  appears,  however,  that  cases  of  necrosis  other  than 
those  due  to  phosphorus  occasionally  lead  to  a  deposit  of 
pumice-like  bone  upon  the  sequestrum.  Mr.  Perry's  case 
of  necrosis  of  the  entire  lower  jaw,  already  alluded  to  (and 
which  will  be  found  m  extenso  in  the  Medico-Chirurgical 
Transactions,  vol.  xxi),  is  a  case  in  point,  the  sequestrum, 
as  may  be  seen  from  the  drawing  given  of  the  preparation 
in  St.  Bartholomew's  Museum,  being  thickly  encrusted  with 
new  bone,  closely  resembling  that  seen  in  phosphorus  cases. 


TEEATMENT    OF    XECliOSIS.  l^S 

The  disease  in  this  case  was  attributed  to  rheumatism,  and 
corresponds  very  closely  to  the  description  given  by  Dr. 
Senftleben  of  the  later  stages  of  acute  rheumatic  periostitis. 
(See  p.  1 02.)  He  says,  "Spontaneous  separation  of  the 
sequestrum  rarely  ensues  ;  it  remains  to  some  extent  in 
organic  connection  with  the  osteophytes  and  ultimately, 
after  a  number  of  months,  a  year,  or  even  more,  an  opera- 
tion has  to  be  performed,  in  which  both  the  sequestrum  and 
the  osteophytes  are  removed  together." 

Treatment  of  Necrosis. — Bearing  in  mind  that  necrosis 
is  not  a  disease  in  itself,  but  is  the  result  of  a  previous 
inflammation,  it  is  evident  that  the  first  aim  of  the  surgeon 
is  to  prevent  this  untoward  result.  With  this  view,  the 
principles  of  treatment  laid  down  in  the  chapter  on  inflam- 
mation and  abscess  should  be  carried  out.  If,  however, 
in  spite  of  treatment  the  inflammation  progresses  and 
necrosis  results,  we  have  to  consider  the  best  way  of 
dealing  with  the  dead  bone.  When  necrosis  has  actually 
taken  place  and  pus  has  formed,  the  tendency  of  the  latter 
is  to  point  either  in  the  mouth  or  on  the  surface  of  the  face. 
In  the  latter  case,  one  or  more  sinuses  will  form,  and  give 
rise  to  great  disfigurement.  Free  incisions  should  therefore 
be  made  through  the  gums,  and  a  free  exit  given  to  the 
pus.  Decomposition  of  the  discharge  must  be  prevented 
as  far  as  possible,  by  the  frequent  use  of  antiseptic  mouth- 
washes and  powders.  Solutions  of  permanganate  of  potash, 
carbolic  acid  or  boracic  acid,  together  with  iodoform  or 
boracic  acid  powders  are  of  great  value.  When  the  patient 
is  unable  to  cleanse  his  mouth  satisfactorily  by  his  own 
efforts,  the  suppurating  cavity  should  be  mopped  out  with 
sponges,  or  washed  out  with  a  syringe  or  suitable  irrigator. 

Since  it  is  impossible  that  the  patient  should  masticate 
solid  food,  it  is  important  that  animal  food  should  be 
prepared  in  a  suitable  manner,  and  this  may  be  attained 
by  making  use  of  soups  or  essences  of  meat,  and  by  reducing 
well-cooked  meat  to  a  mash  with  pestle  and  mortar.  Milk 
and  eggs  form  very  suitable  articles  of  food,  and  may  be 
supplemented  with  wine  or  stout.     At  the  same  time,  drugs 


126  TREATMENT    OF    NECROSIS. 

having  a  tonic  action  may  be  given,  such  as  quinine  and 
iron. 

Most  British  surgeons  agree  in  counselling  non-inter- 
ference with  the  sequestra  in  cases  of  necrosis  until  the 
shell  of  new  bone  around  is  sufficiently  developed  to  main- 
tain the  form  of  the  jaw ;  they  are  then  to  be  extracted 
through  the  mouth,  if  possible,  and  if  not,  through  incisions, 
placed  so  as  to  cause  as  little  subsequent  deformity  as 
possible.  When  the  sequestrum,  although  partially  de- 
tached, is  not  ready  for  removal,  and  greatly  inconveniences 
the  patient,  a  part  may  be  clipped  off  with  the  bone  forceps, 
so  as  to  present  a  smooth  surface,  and  if  the  teeth  are  loose 
and  troublesome  they  had  better  be  removed  at  once,  but 
if  firm  they  should  be  left,  since,  as  has  been  shown,  they 
occasionally  become  useful.  The  caution  already  given, 
against  interfering  with  the  permanent  set  of  teeth  in  cases 
of  necrosis  in  children  should  be  borne  in  mind. 

Some  Continental  surgeons,  however,  interfere  at  an 
early  date,  and  among  them  Professor  Billroth,  who,  accord- 
ing to  the  report  of  the  meeting  of  the  Medical  Congress  at 
Zurich  in  1861  (Medical  Times  and  Gazette,  J nne  8th,  1861), 
"  penetrates  immediately,  with  one  incision,  which  he  makes 
parallel  to  the  necrotic  part,  through  the  skin  down  to  the 
bone ;  he  then  scrapes  off  the  periosteum  with  its  bony 
layers  upwards  and  downwards,  by  means  of  a  raspatorium, 
and  saws  smaller  or  larger  pieces  of  bone  out  of  the  jaw  : 
or  he  nips  those  pieces  off  by  means  of  bone-pincers.  In 
a  few  cases  it  appeared  advisable  to  disarticulate  at  once 
one  or  both  coronoid  and  condyloid  processes  of  the  lower 
jaw,  which  was  very  easily  done,  as  the  joint  had  become 
very  loose  in  consequence  of  the  long  suppuration.  Of  the 
six  cases  shown  by  the  Professor,  two  were  healed,  and 
amongst  them  was  one  of  total  resection  of  the  jaw  in  a 
woman  of  thirty-five  years.  This  case  was  in  so  far  re- 
markable, as  two  apparently  healthy  teeth  had  remained  in 
the  periosteum,  which  had  become  partly  ossified,  and 
in  the  gums,  which  had  remained  healthy ;  and  these 
have  now  been  used  for  seven  months.     Mastication  is  not 


SUB- PERIOSTEAL   EESECTION.  127 

impaired,  and  the  woman  has  a  much  healthier  appearance. 
The  second  case  in  which  the  resection  of  one-half  of  the 
jaw  was  performed,  is  also  well  healed ;  but  the  mouth 
is,  of  course,  crooked.  Two  cases,  in  which  a  partial  re- 
section has  been  made,  are  progressing  favourably  ;  in  an- 
other case  the  treatment  with  mercury  and  iodine  has  been 
commenced." 

When  the  whole  lower  jaw  is  necrosed  it  is  necessary  to 
divide  it  before  it  can  be  extracted.  This  may  be  done,  as 
in  Mr.  Perry's  case,  by  making  a  section  with  the  saw  near 
the  angle  on  each  side  ;  or,  better,  by  dividing  with  the  saw 
at  the  symphysis,  either  without  external  incision,  as  in  Mr. 
T.  Smith's  case,  or  after  reflecting  flaps  of  skin,  as  in  a  case 
of  Sir  J.  Paget's,  wliich  will  be  found  in  the  Lancet,  1862. 
In  a  case  of  necrosis  of  the  entire  lower  jaw,  from  phos- 
phorus, which  was  in  the  London  Hospital  under  Mr. 
Adams'  care,  that  gentleman  preferred  to  divide  the  sym- 
physis with  a  mallet  and  chisel,  and  the  case  is  moreover 
remarkable  from  the  unusual  occurrence  of  secondary 
hemorrhage,  for  which  ligature  of  the  common  carotid 
became  necessary — the  patient  eventually  recovering.  The 
case  will  be  found  in  detail  in  tlie  Medical  Times  and  Gazette^ 
1863. 

Under  the  name  of  "  Sub-periosteal  Eesection,"  operations 
have  been  described  by  foreign  surgeons,  which  in  no 
respect  differ  from  the  extraction  of  sequestra  as  ordinarily 
practised,  and  of  which  the  following  case,  taken  from  the 
Lancet,  of  1863,  is  a  good  example:  "  M.  Pdzzoli,  of 
Bologna,  submitted  to  the  Surgical  Society  of  Paris  a  case 
of  necrosis  of  the  lower  jaw,  from  the  fumes  of  phosphorus, 
in  a  man  aged  fifty-six  years,  in  which  the  sequestra  were 
removed  through  the  mouth.  M.  Eizzoli  made  incisions  on 
either  side  of  the  gums,  scraped  the  thickened  periosteum 
with  a  spatula  from  the  dead  bone,  and  removed  the  latter 
piecemeal.  The  preserved  periosteum  generated  new  bone 
in  the  place  of  the  portions  taken  away^  which  comprised 
the  body  and  part  of  the  ramus  on  each  side.  It  was,  how- 
ever, soon  found  that  the  upper  part  of  the  ramus  and  the 


128  TREATMENT    OF    NECROSIS. 

condyle  were  also  diseased  ;  these  portions  of  bone  were  also 
removed  through  the  mouth  with  the  same  precautions,  and 
the  periosteum  again  acted  in  the  same  way.  Eventually 
the  man  was  able  to  use  his  jaw  and  masticate,  though  de- 
prived of  teeth.  M.  Forget,  who  reported  on  the  case, 
observed,  very  justly,  that  there  was  nothing  new  in  the 
action  of  the  periosteum  in  necrosis  of  bones,  surgeons  having 
long  acted  upon  this  periosteal  property  in  such  cases.  M. 
Flom-ens  had  pointedly  said,  '  Take  away  the  bone,  preserve 
the  periosteum,  and  the  preserved  periosteum  will  restore  the 
bone ;'  but  this  applies  less  to  cases  of  necrosis  of  bone  than 
to  cases  of  experiments  on  animals,  and  operations  performed 
on  healthy  bone  and  periosteum.  And  even  in  these  cases 
it  should  he  remembered  that  osseous  substance  is  reproduced. 
but  not  the  actual  bone  as  it  existed  before  the  resection." 

In  some  cases,  however,  incisions  have  been  made  at  a  com- 
paratively early  stage,  before  the  shell  of  the  new  bone  has 
been  formed,  and  the  sequestrum  immediately  extracted,  with 
good  results.  It  may  be  doubted,  however,  whether  there  is 
any  real  gain  in  such  procedures,  either  in  time  or  result, 
since  the  repair  is  no  more  rapid  than  if  the  sequestrum 
were  left,  and  there  is  the  additional  risk  both  of  the  actual 
operation,  and  of  the  deformity  which  may  result  from  the 
premature  withdrawal  of  the  sequestrum.  A  case  from  the 
practice  of  M.  Maisonneuve,  illustrating  the  practice  in  the 
lower  jaw,  will  be  found  in  the  Com/ptcs  Itendus,  April,  1 86 1 . 
In  his  standard  work,  "  La  Eegeneration  des  Os,"  M.  Oilier, 
of  Lyons,  gives  two  cases  of  subperiosteal  resection,  one  of 
the  upper  and  one  of  the  lower  jaw,  for  necrosis,  in  neither 
of  which  was  there  any  osseous  development ;  and  these 
cannot,  therefore,  be  regarded  as  very  satisfactory  examples 
of  a  proceeding  whose  great  aim  is  the  development  of  new 
bone. 

With  regard  to  the  prevention  of  phosphorus-necrosis,  the 
following  extract  from  Mr.  Simon's  report  to  the  Privy 
Council  (1863),  may  be  quoted  with  advantage,  as  giving 
the  results  of  Dr.  Bristowe's  careful  investigation  of  the 
subject :    "  The    dangers    to    which    I    have    adverted,    as 


niECAUTIOXARY   MEASURES.  129 

belonging  to  the  phosphorus  industry,  belong  exclusively  to 
working  with  common  phosphorus.  Working  with  amor- 
phous phosphorus  is  unattended  with  danger  to  health. 
Since,  however,  it  appears  that,  with  reasonable  precautions, 
the  use  of  common  phosphorus  for  match-making  need  not 
be  an  unwholesome  occupation,  I  cannot  say  that,  in  my 
opinion,  the  substitution  of  amorphous  for  common  phos- 
phorus in  the  manufacture  is,  for  sanitary  purposes,  an 
object  to  be  unconditionally  insisted  on.  Yet  having  regard 
to  the  fact  that  amorphous  phosphorus  not  only  is  manufac- 
tured without  danger  to  the  worker,  but  that  its  use  in 
lucifer  boxes  also  involves  infinitely  less  danger  of  fire  than 
belongs  to  common  lucifer  matches,  I  think  that  the  substi- 
tution is  altogether  one  to  be  desired.  And,  of  course,  with 
reference  to  any  restriction  which  the  legislature  might  think 
of  imposing  on  the  utilization  of  common  phosphorus,  it 
would  deserve  to  be  remembered  that  manufacturers  would 
have  at  their  option  the  alternative  of  using,  without  restric- 
tion, the  innocuous  amorphous  material." 


CHAPTEK  X. 

HYPEEOSTOSIS. 

Under  the  liead  of  diffused  hyperostosis  it  will  be  con- 
venient to  group  together  those  remarkable  examples  of 
hypertrophy  of  the  maxillse,  and  more  or  less  of  other  bones 
of  the  face  and  cranium,  which  have  occurred  from  time  to 
time,  and  have  been  recorded  by  Howship,  Griiber,  Astley 
Cooper,  Bickersteth,  and  others.  These  cases  form  a  group 
of  diseases  of  bone  of  which  we  know  very  little  as  to  either 
their  etiology  or  pathology.  They  seem  to  fall  into  two 
chief  divisions. 

1 .  In  this  group  the  hypertrophy  is  limited  to  the  jaws 
or  the  bones  of  the  face  or  cranium,  and  may  be  called 
Diffused  Hyperostosis. 

2.  In  some  cases  the  hypertrophy  is  not  limited  to  the 
bones  of  the  face  or  cranium,  but  may  involve  other  bones, 
especially  those  of  the  extremities.  For  an  accurate  descrip- 
tion of  these  cases  we  are  indebted  to  P.  Marie. 

Diffused  Hyperostosis  of  Face  and  Cranium. — In  these 
cases  the  aspect  of  the  face  may  be  considerably  changed, 
presenting  a  somewhat  leonine  aspect,  for  which  reason 
Virchow  applied  the  term  "  leontiasis  ossea." 

One  of  the  earliest  cases  was  put  on  record  by  Mr. 
Howship  in  his  "  Practical  Observations  in  Surgery  "  (i  8 16). 
The  patient,  when  about  forty-five  years  of  age,  and 
apparently  in  perfect  health,  was  exposed  to  a  cold  wind, 
immediately  after  which  he  perceived  an  itching  and  heat 
in  his  eyes,  and  swelling  of  the  face  rapidly  supervened.  A 
small  tumour  formed  just  below  the  inner  angle  of  each  eye, 
which  burst,  and,  after  twelve  weeks,  he  was  able  to  resume 


HOWSHIP'S    CASE    OF    HYPEROSTOSIS.  131 

his  employment.  He  suffered  from  inflammatory  attacks 
in  the  tumours,  with  much'  pain  in  the  head,  on  more  than 
one  occasion,  and  consulted  many  medical  men,  but  no 
treatment  relieved  the  disease  or  retarded  the  growth  of  the 
tumours,  which  increased  slowly,  and  were  of  stony  hardness. 
The  eyes  were  projected  from  the  orbits  by  the  tumours,  and 
the  right  eye  inHamed  and  burst,  while  the  left  was 
accidentally  ruptured  by  a  blow.  The  patient  lived  to  over 
sixty  years  of  age,  and  died  of  apoplexy,  having  been 
occasionally  maniacal  during  the  last  two  years  of  his  life. 

Fig.  48. 


The  accompanying  portrait  (i'ig.  48)  is  taken  from  Mr. 
Howship's  work.  The  skull  of  this  patient  is  preserved  in 
the  College  of  Surgeons,  and  shows,  as  might  be  anticipated 
from  the  portrait,  two  large  masses  of  almost  exactly 
symmetrical  form  and  arrangement,  which  have  partially 
coalesced  in  the  median  line.  The  growths  are  as  hard  as 
ivory,  and  consist  of  a  very  close  cancellous  structure.  They 
project  more  than  three  inches  in  front  of  the  face,  and  an 
inch  beyond  the  malar  bones  on  each  side  :  they  completely 
fill  both  orbits,  the  cavities  of  the  nose,  and,  probably,  both 
antra,  and  they  extend  as  far  backwards  as  the  pterygoid 
plates  of  the  sphenoid  bone.  In  the  Catalogue  of  the 
Museum  it  is  stated  that  the  man  attributed  the  arowths  to 


132  HYPEROSTOSIS    OF    THE    JAWS. 

repeated  blows  received  on  the  face  in  fighting,  but  Mr. 
Howship  makes  no  mention  of  this ;  and  the  information 
was  probably  derived  from  Mr.  Langstaff,  in  whose  collection 
the  preparation  originally  was. 

A  skull  of  a  Peruvian,  also  in  the  Museum  of  the  College 
of  Surgeons,  exhibits  the  same  form  of  disease,  but  of  a  more 
diffused  character,  all  the  bones  of  the  face,  as  well  as  the 
frontal  and  the  adjacent  parts  of  the  sphenoidal  and  parietal 
bones,  being  enlarged  and  thickened  in  a  remarkable  manner. 
The  nasal  fossai  and  orbits  are  nearly  closed,  the  superior 
maxillary  bones,  and  the  orbital  portions  of  the  malar  and 
frontal  bones,  having  grown  into  great  knobbed  and  tuber- 
cular masses,  in  which  their  original  form  can  be  hardly 
discerned.  The  hard  palate  is  similarly  diseased.  The 
lower  jaw  is  enormously  enlarged  at  its  right  angle,  and  in 
the  greater  part  of  its  right  half  it  measures  upwards  of 
five  inches  in  circumference,  and  all  but  three  of  its  alveoli 
are  closed  up.  A  section  of  the  lower  jaw  shows  that  its 
interior  is  composed  of  an  almost  uniformly  hard  and  com- 
pact, but  finely  porous,  bone.  There  is  no  history  attached 
to  the  specimen. 

Sir  Astley  Cooper's  patient  was  a  Billingsgate  fish-woman, 
long  remarkable  for  her  hideous  appearance,  who  died  of 
apoplexy  in  St.  Thomas's  Hospital,  in  thB  museum  of  which 
institution  the  skull  is  preserved.  In  connection  with  each 
superior  maxilla  is  a  rounded  bony  growth,  extending  from 
the  lower  margin  of  the  orbit  to  the  roots  of  the  alveolar 
processes.  The  cavity  of  each  antrum  is  occupied  by  the 
growth,  which  by  its  projection  has  encroached  upon  the 
nasal  fossse,  and  filled  the  frontal  and  ethmoidal  sinuses. 
The  case,  therefore,  closely  resembles  Mr.  Howship's 
specimen. 

Mr.  Bickersteth's  very  remarkable  specimen  was  exhibited 
to  the  Pathological  Society  of  London  in  April,  1866, 
by  Dr.  Murchison,  and  its  description  in  the  Society's 
Transactions  is  illustrated  with  admirable  lithographic 
■drawings. 

The   patient,  who  died  at  the  age  of  thirty-four,   first 


bickeesteth's  case  of  hyperostosis.  133 

noticed  an  enlargement  of  the  bones  of  the  face  when  a  boy 
of  fourteen.  The  swelling  of  the  face  gradually  increased, 
and  thirteen  years  after  its  commencement  a  similar  hard 
swelling  appeared  along  the  course  of  the  left  fibula.  About 
two  years  before  death  he  began  to  suffer  severe  pain,  which 
continued  to  his  death,  this  being  the  result  of  emaciation, 
consequent  upon  the  encroachment  of  the  disease  upon  the 
mouth.  All  the  bones  of  the  head  are  more  or  less  involved 
in  the  disease,  with  the  remarkable  exception  of  the  occipital 
bone.  The  malar  bones  are  developed  into  dense  globular 
masses,  the  size  of  an  orange.  The  palatal  processes  of  the 
superior  maxillte  are  also  greatly  diseased,  a  rounded  mass 
projecting  down  on  each  side  so  as  to  fill  up  the  cavity  of 
the  hard  palate  to  a  level  with  the  alveolar  ridge.  The 
lower  jaw  is  enormously  thickened  in  every  direction,  the 
right  side  more  so  than  the  left.  Little  trace  can  be  seen 
of  a  condyle,  coronoid  process,  or  sigmoid  notch,  the  whole 
being  fused  into  one  uniform  globular  mass. 

A  very  elaborate  account  of  the  specimen,  with  measure- 
ments and  microscopical  appearances  by  Mr.  De  Morgan, 
will  be  found  in  the  seventeenth  volume  of  the  Pathological 
Society's  Transactions,  from  which  the  above  is  condensed. 

A  fourth  specimen  is  preserved  in  the  Musee  Dupuytren, 
in  which  both  upper  and  lower  jaws  are  extensively  affected  ; 
and  specimens  showing  the  disease  in  a  lesser  degree  will 
be  found  in  the  museum  of  the  Dental  Hospital,  Leicester 
Square,  and  elsewhere. 

In  all  these  specimens  the  external  surface  of  the  bones 
affected  is  more  or  less  coarsely  tuberculated  ;  the  tissue  is 
hard  and  dense,  and  minutely  perforated  for  the  passage  of 
blood-vessels.  In  the  case  of  the  lower  jaw  of  the  Peruvian 
skull,  the  interior  is  composed  of  an  almost  uniformly  hard 
and  compact,  but  finely  porous  bone.  Traces  of  the  original 
walls  of  the  jaw  are  discernible  nearly  an  inch  beneath  the 
surface  of  the  most  enlarged  part,  but  its  interior  is  filled  up 
with  the  same  kind  of  osseous  substance  as  that  which  is 
outside  the  trace  of  the  wall. 

A  microscopical  examination  of  the  St.  Thomas's  Hospital 


134  HYPEKOSTOSIS    OF    THE    JAWS. 

specimen  "  shows  it  to  consist  of  two  kicds  of  bony  matter  ; 
one  firm  and  compact,  while  the  other  is  more  or  less  soft 
and  spongy.  In  the  former,  Haversian  canals  occur,  having 
concentric  laminse  around  them,  but  in  the  spongy  portion 
cancelli  only  are  present,  and  the  bone  exhibits  a  granular 
structure,  with  numerous  bony  cells  arranged  in  no  definite 
order." 

In  Mr.  Bickersteth's  specimen,  "  The  compact  structure 
is  traversed  in  every  direction  by  large  branching  and  com- 
municating vascular  canals,  forming  in  some  places  a  close 

network The  spaces  between   the  canals  are  filled 

up  by  bone-tissue  of  ordinary  character.  The  lacunae  are 
in  general  very  numerous,  but  they  are  small^  and  for  the 
most  part  elongated.  Very  few  traces  of  true  Haversian 
systems  are  to  be  seen," 

It  is  stated  in  the  report  upon  the  last  specimen,  that  the 
microscopical  appearances  are  nearly  identical  with  those  of 
the  Peruvian  skull  in  the  Hunterian  Museum. 

In  the  Museum  of  St.  Bartholomew's  Hospital  is  a 
specimen  showing  obliteration  of  the  antra,  due  to  hyper- 
trophy of  the  bone,  of  the  same  character  as  in  the  specimen 
described  above,  but  in  an  earlier  stage.  Mr.  Stanley  ("  On 
Diseases  of  the  Bones,"  p.  297)  gives  the  case  of  a  girl  of 
fifteen  years  in  whom  enlargement  of  the  nasal  process  of 
the  superior  maxillse  had  been  observed  for  eight  years,  and 
was  increasing.  There  was  no  external  deformity,  but  it 
was  thought  advisable  to  interfere  at  an  early  date,  when 
it  was  found  that  obliteration  of  th>:'.  antrum  had  already 
taken  place,  as  in  the  preceding  case.  The  entire  jaw  was 
removed,  but  the  patient  unfortunately  died  of  erysipelas. 

In  the  Museum  of  King's  College  is  another  specimen, 
which  shows  well  the  obliteration  of  the  antrum  by  hyper- 
trophy of  its  walls.  The  tumour  was  removed  in  1842,  by 
Sir  William  Fergusson,  from  a  girl  of  twelve,  in  whom  some 
enlargement  of  the  face  had  been  noticed  from  the  age  of 
four,  and  whose  portrait  is  shown  in  Fig.  49,  taken,  by 
permission,  from  that  eminent  surgeon's  "  Practical  Surgery." 
The  patient  made  a  perfect  recovery,  and  the  particulars  of 


FERGUSSON'S  CASE  OF  HYPEROSTOSIS. 


135 


the  case  will  be  found  in  the  Lancet  oi  February  and  March, 
1842.  Fig.  50  shows  her  portrait  after  recovery  from  the 
operation. 

In  the  same  museum  is  a  specimen  of  the  disease  in  the 
ramus  of  the  lower  jaw,  removed  by  the  same  surgeon  from 
a  girl  of  thirteen,  by  sawing  in  front  of  the  molar  teeth  and 
disarticulating.      The  patient  made  a  good  recovery. 

I  have  now  met  with  several  cases  more  or  less  closely 


Fig.  49 


Fig.  50. 


resembling  those  described  above.  The  most  marked  one 
was  in  a  lady,  aged  thirty-nine,  who  had  a  blow  on  the 
right  cheek  when  fourteen,  and  noticed  an  outgTOwth  when 
about  eighteen.  "When  she  was  brought  to  me  by  Mr. 
Salzmann,  of  Brighton,  I  found  a  very  marked  projection 
of  the  right  cheek,  due  to  an  enlargement  of  the  superior 
maxilla,  which  was  smooth  and  uniform  on  its  surface. 
Without  any  external  incision  I  succeeded  in  gouging  away 
a  cj[uantity  of  dense  bone  without  opening  any  antral  cavity, 
and  thus  reduced  the  face  to  a  symmetrical  appearance. 
The  cure  has,  I  believe,  been  permanent. 


136 


HYPEEOSTOSIS    OF   THE    JAWS. 


A  remarkable  case  of  hyperostosis  with  hypertrophy  of 
the  tissues  of  the  corresponding  side  of  the  face  has  been 
under  my  notice  for  fourteen  years.  The  patient,  a  healthy 
boy,  aged  twelve,  was  sent  to  me  in  November,  1869,  by 
Mr.  Giles,  of  Staunton-on-Wye,  under  whose  care  he  had 
been  from  birth.  When  three  months  old  the  patient's  face 
was  noticed  to  be  enlarged  on  the  left  side,  and  this 
enlargement  gradually  increased  until  he  presented  the 
appearance  shown  in  Fig.  5  i ,  from  a  photograph  taken  in 

Fig.  51. 


1869.  The  left  superior  maxilla  had  shared  in  the  hyper- 
trophy, and  the  condition  of  the  palate  and  teeth  is  shown 
in  Fig.  5  2,  reduced  from  a  cast,  where  it  will  be  seen  that 
the  temporary  incisors  and  canine  teeth  are  still  in  situ  on 
the  diseased  side,  though  they  have  been  replaced  by  the 
permanent  teeth  on  the  healthy  side.  I  removed  the  left 
superior  maxilla  on  December  ist,  1869,  in  the  hope  that 
the  removal  of  the  bone  and  the  necessary  incisions  in  the 
cheek  would  lead  to  a  permanent  relief  of  the  deformity.  The 
patient  made  a  perfectly  good  recovery,  and  I  subsequently 
endeavoured  to  open  the  eye  and  to  destroy  a  portion  of  the 
tissue  of  the  cheek,  but  without  much  permanent  success. 


AUTHOK.S    CASE    OF    HYPEROSTOSIS. 


137 


the  patient's  condition  two  years  after  the  operation  being 
as  unsightly  as  before.  In  1883  I  received  from  Mr. 
Giles  later  photographs  of  this  patient,  which  show  that 
the  hypertrophy  of  the  soft  parts  has  kept  pace  with  the 
patient's  growth. 

A  section  of  the  removed  upper  jaw  showed  considerable 
condensation  of  the  bone,  and  the  fact  that  the  permanent 
incisors  and  canine  teeth,  together  with  the  uncut  molars, 
were  imbedded  in  the  bone,  and  holding  very  much  their 
natural  relations  to  the  temporary  teeth  (Fig.  53).  Mr. 
Charles  Tomes,  who  kindly  examined  the  specimen  micro- 
scopically, reported  that  "  the  structure   is   remarkable    on 


Fig.  52. 


Fig. 51 


account  of  the  absence  of  well-developed  regular  Haversian 
systems.  The  bone  is  everywhere  excavated  by  large 
irregular  spaces,  around  which  there  is  but  little  appearance 
of  lamination,  so  that  it  presents  some  little  resemblance  to 
so-called  'primary  bone';  the  lacunae  are  arranged  somewhat 
irregularly.  None  of  the  peculiar  branched  vascular  canals, 
figured  by  Mr.  De  Morgan  in  his  account  of  the  microscopic 
characters  of  Mr.  Bickersteth's  case,  were  observed  in  their 
sections.  That  the  whole  of  the  bone  has  from  an  early 
period  participated  in  the  morbid  action  is  indicated  by  the 
fact  that,  although  the  teeth  have  attained  to  something  like 
the  stage  of  development  appropriate  to  the  patient's  age,  the 
alveolar  border  has  not  the  development  of  the  jaw  in  the 
antero-posterior  direction,  being  insufficient  to  allow  of  the 
second  permanent  molar  coming  down  and  ranging  with  the 


138  HYPEKOSTOSIS    OF    THE   JAWS. 

other  teeth.      The  second  molar  is   a  small  tooth,  and  the 
wisdom  tooth  is  greatly  stunted." 

Etiology. — Most  of  the  cases  have  presented  early  in  their 
course  symptoms  pointing  to  an  inflammatory  condition  of  the 
bone,  affecting  probably  both  the  periosteum  and  the  osseous 
substance.  The  cause  of  this  inflammatory  condition  it  seems 
impossible  definitely  to  state.  It  appears  to  be  entirely 
unconnected  with  syphilis  or  tubercle,  and  to  be  completely 
beyond  the  control  of  remedies.  Some  of  the  cases  have 
followed  a  blow,  such  as  a  kick  from  a  horse,  and  it  is 
possible  that  the  inflammation  thus  caused  may  have  started 
the  disease.  There  is  nothing  to  support  the  view  of 
Hushche  that  the  hyperostosis  may  be  a  manifestation  of 
rickets.  The  most  probable  explanation  is  that  offered  by 
Virchow  and  0.  Weber.  These  observers  consider  that 
erysipelas,  which  has  been  a  marked  feature  in  some  of  the 
cases,  has  started  the  disease.  They  look  upon  the  hyper- 
trophy as  analogous  to  the  elephantiasis  that  may  occur  in 
soft  tissues,  and  which  is  generally  closely  associated  with 
erysipelas. 

Treatment. — Drugs  seem  to  have  no  influence  upon  these 
cases.  Lesser  degrees  of  enlargement  of  both  upper  and 
lower  jaws  of  the  same  kind  are  not  very  uncommon,  and 
in  one  or  two  patients  I  have  certainly  seen  good  follow  the 
prolonged  administration  of  the  syrup  of  iodide  of  iron.  It 
is  very  doubtful,  however,  whether  these  were  really  cases  of 
diffused  hyperostosis.  In  the  31st  vol,  of  the  Patliological 
Society  s  Transactions,  Mr.  E.  W.  Parker  gives  a  drawing  of 
remarkable  symmetrical  hyperostoses  of  the  angles  of  the 
lower  jaw  in  a  girl  of  twelve,  which  he  considers  to  be  the 
result  of  congenital  syphilis,  and  the  subsequent  history 
confirmed  the  diagnosis,  the  gummata  disappearing  under 
treatment.  I  have,  however,  twice  been  consulted  for 
precisely  similar  hypertrophy  of  the  angles  of  the  jaws 
occurring  in  perfectly  healthy  young  women,  one  being  the 
daughter  of  a  medical  friend,  in  whom  there  was  no  suspicion 
of  congenital  taint. 

When  the  disease  afiects  only  one  of  the  maxillae,  which 


GENERAL    DIFFUSED    HYPEROSTOSIS.  139 

is  its  favourite  seat,  operative  interference  will  be  advisable. 
Several  cases  have  been  already  mentioned  where  removal  of 
the  hypertrophied  maxilla  was  followed  by  a  successful 
result. 

The  cases  of  "  Osteitis  deformans  "  described  by  Sir  James 
Paget  {Mcdico-Clbirurgiml  Transactions,  vol.  li)  do  not  come 
into  the  same  category  as  the  cases  given  above,  for  though 
the  cranium  is  often  affected,  the  facial  bones  have  a 
singular  immunity  from  that  disease.  In  several  of  these 
cases  also  there  was  found  cancer  in  some  part  of  the  body. 
But  that  cancer  may  co-exist  with  hyperostosis  of  the  jaw 
bones  is  shown  by  a  case  recorded  by  Dr.  Cayley  (FatJiological 
Society's  Trans.,  vol.  xxix),  where  cancer  of  the  lung  was 
found  together  with  hyperostosis  of  the  lower  jaw,  which 
presented  the  following  appearances  :  "  The  lower  jaw  was 
uniformly  enlarged  and  the  alveolar  border  projected  beyond 
that  of  the  upper  one,  with  which  it  could  not  be  brought 
into  apposition.  All  the  molar  and  pre-molar  teeth  were 
wanting,  and  the  sockets  of  the  molar  teeth,  except  that  for 
the  first  right  and  the  last  left  one,  were  filled  up  with  bone  ; 
the  socket  of  the  first  right  molar  was  much  enlarged  and 
would  admit  the  tip  of  the  little  finger :  it  was  continuous 
with  the  socket  for  the  adjacent  bicuspid,  which  had  itself 
ulcerated  through  the  anterior  surface  of  the  jaw.  The 
alveolar  border  of  the  bone  was  greatly  expanded,  especially 
in  the  molar  regions,  where  it  measured  in  depth  two  inches 
and  a  half.  The  rest  of  the  bone  was  also  greatly  increased 
in  thickness,  the  groove  and  foramen  for  the  inferior  dental 
vessels  and  nerve  were  remarkably  deep  and  wide.  The 
condyle  on  each  side  had  a  short  thick  neck,  and  the  sigmoid 
notch  was  wider  and  less  deep  than  usual.  The  angle  was 
very  obtuse,  as  in  edentulous  jaws." 

General  Diffused  Hyperostosis. — P.  Marie  has  divided  these 
cases  into  two  classes. 

The  form  more  frequently  met  with  he  terms  Aeromegcdy. 
In  these  cases  there  is  hypertrophy  of  the  soft  tissues  as 
well  as  of  the  bones.  The  bones  chiefly  affected  are  the 
distal  extremities  of  the  limbs,  the  lower  jaw  and  the  bones  of 


140  HYPEKOSTOSIS   OF    THE    JAWS. 

the  cranium.     The  enlargement  of  the  lower  jaw  may  be  a 
very  prominent  feature  in  the  case. 

In  the  other  class  there  is  no  affection  of  the  soft  parts, 
and  the  jaws  are  very  seldom  involved.  In  exceptional 
cases  the  superior  maxillae  have  been  found  enlarged.  These 
cases  seem  to  be  connected  with  various  chronic  pulmonary 
diseases,  and  P.  Marie  looks  upon  this  connection  as  more 
than  accidental  (Revue  de  Medecine,  A-^xW,  1886). 


CHAPTEE  XI. 

DISEASES    OF    THE  ANTRUM. 

Befoee  entering  upon  the  consideration  of  the  diseases  of 
the  antrum,  it  will  be  convenient  to  say  a  few  words  re- 
specting the  anatomical  relations  of  that  cavity.  Known  as 
early  as  the  time  of  Galen,  but  connected  inseparably  with 
the  name  of  Highmore,  who  described  it  as  "  conical  and 
somewhat  oblong,"  the  antrum  has  been  more  or  less  cor- 
rectly described  by  all  modern  anatomists.  Holden  com- 
pares it  aptly  enough  to  "  a  triangular  pyramid,  with  the 
base  towards  the  nose  and  the  apex  towards  the  malar 
bone ;  "  and  mentions  the  occurrence  of  "  thin  plates  of  bone 
which  are  often  found  extending  across  the  antrum."  The 
accompanying  illustration,  copied  from  Testuit^s  TraiU  cV Ana- 
tomic humaine,  shows  the  antrum  exposed  by  removal  of  its 
outer  wall  (Fig  54).  The  most  comprehensive  account  of 
the  antrum  in  modern  times  is  to  be  found  in  a  paper  by  the 
late  Mr.  W.  A.  N.  Cattlin,  F.E.C.S.,  in  vol.  ii  of  the 
Transactions  of  the  Odontologiccd  Society  of  London,  and  I  am 
enabled  to  reproduce  some  of  his  valuable  illustrations. 

As  the  result  of  the  examination  of  a  hundred  specimens, 
Mr.  Cattlin  found  that,  as  a  rule,  the  antrum  is  larger  in  the 
niale  than  in  the  female,  and  that  it  diminishes  in  size  with 
extreme  age.  In  the  young  subject,  likewise,  the  cavity  is 
small,  and  its  walls  comparatively  thick.  Fig.  5  5  shows, 
in  a  transverse  section,  both  the  roof  and  floor  of  an  adult 
antrum  of  the  common  shape  and  size,  capable  of  containing 
two  and  a  half  drachms  of  fluid.  The  capacity  of  the 
antrum  varies  between  one  drachm  and  eight  drachms  of 
fluid.     The  two  antra  are  often  unsymmetrical  both  in  size 


142 


DISEASES    OF    THE  ANTRUM. 


and  shape.     The  antrum  may  extend  into  the  malar  bone, 
forming   an    irregular    supplementary    cavity    there.     The 

Fig.  54. 


most  remarkable  variation,  however,  is  due  to  the  develop- 
ment of  ridges  of  bone  which  subdivide  the  antrum  into 

Fig.  155. 


cavities  of  varying  size  and  shape.  FossEe  of  considerable 
size  are  often  found  in  the  floor  of  the  antrum,  particularly 
at  the  anterior  and  posterior  extremities,  of  which  Tig.  56  is 
a  good  example,  showing  on  one  side  a  perforation  by  an 


ANATOiMY    OF    THE    ANTRUM. 


141 


alveolar  abscess.  A  rare  form  is  when  fossa3  or  cells  are 
developed  beneath  the  orbital  plate,  or  a  cul  de  sac  is  formed 
close  to  the  lachrymal  groove.  The  position  and  size  of 
the  opening  between  the  antrum  and  the  middle  meatus  of 
the  nose  are  points  of  some  importance.  The  size  of  the 
aperture  found  in  a  macerated  superior  maxilla  gives  a  very 
exaggerated  idea  of  the  opening  in  the  articulated  skull, 
when  it  is  encroached  upon  by  the  palate,  inferior  turbinated 

Fig.  56. 


and  ethmoid  bones,  which  narrow  and  subdivide  the  opening 
into  two.  In  the  recent  subject  these  are  covered  in  by 
the  mucous  membrane  of  the  nose,  so  that  as  a  rule  there  is 
only  a  small  oblique  aperture  left  in  front  of  the  unciform 
process  of  the  ethmoid  and  close  behind  the  infundibulum. 

It  should  be  observed  that  this  opening  is  at  the  upper  part 
of  and  not  near  the  floor  of  the  antrum,  and  that  it  opens 
into  the  miclclU  meatus  of  the  nose.  Occasionally  a  second 
small  aperture  is  found  behind  this,  and  nearer  to  the  floor 
of  the  sinus,  which  has  been  regarded  as  a  natural  formation. 


144  DISEASES    OF   THE   ANTKLJM. 

M.  Grirald^s,  however,  in  his  Rechcixhes  sur  les  Kystcs 
Muqueux  du  Simis  Maxillaire  (Paris,  i860),  maintains 
that  the  posterior  opening,  when  it  exists,  is  always  the 
result  of  pathological  change,  and  that  the  anterior  opening 
is  into  the  infundibulum,  and  not  into  the  meatus  itself.  I 
believe  that  slight  variations  in  the  position  of  the  normal 
opening  exist.  There  is  no  doubt  that  the  opening  is 
small,  frequently  guarded  by  a  valvular  flap  of  mucous 
membrane,  and  generally  considered  to  be  inaccessible  to 
the  passage  of  instruments  from  the  nose.  Zuckerkandl, 
in  his  Normale  unci  patliologische  Anatomie  der  Nasenhohle 
imd  Hirer  pneumatischen  Anlidnge  (Wien.  1882),  gives 
measurements  of  the  ostium  maxillare.  The  smallest  was 
3  millimetres  in  diameter,  and  the  largest  was  19  mm.  long 
and  5  mm.  broad.  The  average  measurement  was  7  to  1 1  mm. 
in  length  and  2  to  6  mm.  in  breadth.  Its  inaccessibility 
from  the  anterior  nares  is  due  to  two  causes — one,  the 
situation  of  the  valvular  flap  of  mucous  membrane  which 
conceals  the  orifice  from  view ;  the  other  obstacle  is  due  to 
the  downward  projection  of  the  middle  turbinated  bone. 

Theodore  Heryng,  however,  in  a  paper  in  the  British 
Journal  of  Dental  Science  (1889),  makes  the  following 
observation :  "  I  find  that  with  a  little  practice  it  is  very 
■easy  to  probe  the  maxillary  bone  after  using  cocaine,  and  in 
the  majority  of  cases  without  causing  the  patient  any  pain. 
The  probe  I  use  is  an  ordinary  thin  one  provided  with  a 
knob  and  bent  at  a  right  angle,  the  short  arm  of  which 
must  be  about  8  mm.  long.  It  is  introduced  by  means  of 
Duplay's  speculum  for  a  distance  of  about  two  inches  into 
the  middle  nasal  meatus,  with  the  beak  looking  down.  It 
is  then  rotated  slightly  towards  the  outer  wall,  and  gently 
drawn  forward  and  inserted  sideways  into  the  ostium.  If  it 
finds  the  opening  it  gets  hooked  in.  It  is  easy  to  measure 
the  size  of  the  opening  by  gently  moving  the  probe  back- 
wards and  forwards.  As  a  rule  it  is  about  3  or  4  mm. 
wide.  In  one  case  only — one  of  distension  of  the  antrum 
with  swelling  of  the  cheek — I  found  it  impossible  to  intro- 
duce the  probe." 


ETIOLOGY    OF    EMPYEMA   ANTRI.  145 

The  disease  of  the  antrum  may  be  divided  into  the 
following  groups  : 

1 .  Inflammation  and  suppuration — Empyema  antri. 

2.  Fistulse  of  the  antrum. 

3.  Cystic  disease — Hydrops  antri. 

4.  Tumours  of  the  antrum. 

I.  Infiammation  and  Suppuration. — Although  in  practice 
we  only  meet  with  cases  of  inflammation  of  the  antrum 
which  have  gone  on  to  suppuration  of  the  lining  membrane, 
yet  there  is  no  doubt  that  a  catarrhal  inflammation,  probably 
lasting  a  considerable  time,  has  preceded  the  formation  of 
pus.  The  catarrhal  inflammation,  however,  gives  rise  to  no 
symptoms  so  far  as  we  know  at  present,  and  therefore  we 
only  discover  these  cases  when  the  antrum  is  distended 
with  pus. 

Formerly  abscess  of  tlie  antrum,  or  "  Empyema  antri,'^  as 
it  has  been  called  by  0.  Weber,  was  regarded  as  a  rare 
disease,  but  of  recent  years  it  has  been  frequently  met  with, 
especially  since  the  publication  by  Ziem  of  his  paper  on  the 
subject  in  1886.  Owing  to  the  difficulty  of  diagnosis,  no 
doubt  many  cases  were  formerly  overlooked.  Up  to  1888 
Ziem  had  treated  the  astounding  number  of  227  cases. 

Miology. — So  far  as  we  know,  the  inflammation  never 
commences  in  the  antrum  itself,  but  the  lining  membrane  is 
invaded  by  inflammation  from  neighbouring  structures. 
Hence  probably  in  all  cases  the  disease  is  secondary  to 
inflammation  elsewhere.  In  the  large  majority  of  cases  the 
primary  trouble  is  either  in  the  teeth  or  the  nose.  There 
is  considerable  difference  of  opinion  regarding  the  relative 
frequency  with  which  these  causes  act.  I  believe  that 
inflammatory  conditions  of  the  teeth  are  by  far  the  most 
frequent  cause.  The  roots  of  the  first  and  second  molar 
teeth  often,  and  tlie  bicuspids  and  canine  occasionally,  form 
prominences  in  the  floor  of  the  antrum  ;  and  when  these 
teeth  become  carious,  the  thin  plate  of  bone  covering  their 
fangs  not  unfrequently  becomes  affected,  and  disease  is 
set  up  in  the  cavity.  The  fangs  of  the  first  molar  tooth 
are  occasionally  found  in  health  to  be  uncovered   by  bone, 

K 


146  .   DISEASES    OF   THE    ANTRUM. 

and  to  project  beneath  the  lining  membrane  of  the  antrum ; 
and  under  these  circumstances,  irritation  and  inflammation 
would  be  still  more  likely  to  occur.  But  an  abscess  may  be 
formed  in  the  alveolus,  and  eventually  burst  into  the  antrum, 
though  connected  originally  with  teeth  not  usually  in 
relation  with  the  cavity.  Of  this  a  case  was  described  to 
me  by  Mr.  Margetson,  of  Dewsbury,  where  the  teeth 
affected  were  the  canine  and  incisors.  This  perforation  of 
an  alveolar  abscess  isseen  also  in  Fig.  56. 

Frankel  is  strongly  of  opinion  that  the  chief  cause  of 
abscess  of  the  antrum  is  to  be  found  in  inflammatory 
conditions  of  the  alveolar  periosteum.  He  also  points  out 
that,  of  all  the  accessory  cavities  of  the  nose,  the  antrum  is 
the  one  most  commonly  affected,  a  point  strongly  in  favour 
of  the  dental  origin  of  the  disease. 

Zuckerkandl  and  others,  however,  believe  that  the  primary 
trouble  more  often  arises  in  the  nose.  There  is  no  doubt 
that  in  some  cases  infection  may  come  from  the  nose. 
Thus,  Bayer  has  published  several  cases  of  polypoid  degene- 
ration of  the  mucous  membrane  of  the  middle  meatus  leading 
to  empyema  antri.  Gerard-Marchant,  in  the  TraiU  de 
Ghirurgie  of  Duplay  and  Reclus,  mentions  a  case  of  acute 
catarrh  of  the  nose  in  influenza  that  was  followed  by  abscess 
in  the  antrum. 

Among  rare  causes  of  antral  abscess  we  may  mention 
blows  on  the  face,  leading  to  fracture  and  suppurative  ostitis 
of  the  superior  maxilla ;  operations  on  the  face,  as  in  the  two 
cases  of  resection  of  the  infra-orbital  nerve,  mentioned  by 
Lano-enbeck  ;  violent  blows  on  the  face  without  fracture  of  the 
bone  ;  syphihtic  necrosis  of  the  superior  maxilla ;  and  finally, 
the  entrance  of  foreign  bodies,  as  in  a  case  recorded  by 
Mr.  Moore  in  the  third  volume  of  Transactions  of  the  Clinical 
Society,  in  which,  he  believed  the  abscess  to  be  due  to  the 
ingress  of  particles  of  food  by  the  side  of  a  tooth,  though 
the  facts  might  possibly  bear  a  different  interpretation. 

Symptoms. — Owing  to  the  more  accurate  study  of  antral 
abscess  of  recent  years,  the  description  of  the  symptoms 
which  was  generally  accepted  as  characteristic  of  the  disease 


SYMPTOMS    OF    EMPYEMA    ANTKI.  147 

has  had  to  be  modified.  Thus,  it  was  stated  in  the  last 
edition  of  this  book  that  "  tlie  symptoms  of  suppuration  in 
the  antrum  are  at  first  simply  those  of  inflammation  of  the 
lining  membrane — dull,  deep-seated  pain  shooting  up  the 
face  and  to  the  forehead,  tenderness  of  the  cheek,  with 
some  fever  and  constitutional  disturbance  ;  but  occasionally 
the  pain  is  most  acute,  and  of  a  sharp,  stabbing,  neuralgic 
character.  A  slight  rigor  may  usher  in  the  formation  of 
matter,  which  will  find  its  way  into  the  nostril  when  the 
patient  is  lying  on  his  sound  gide." 

Although  this  description  applies  accurately  enough  to 
one  form  of  antral  abscess,  yet  it  does  not  apply  to  the  large 
majority.  Tor  we  have  to  remember  that  the  symptoms 
vary  according  to  the  amount  of  drainage  that  can  take 
place  through  the  ostium  maxillare,  and  hence  it  is  convenient 
to  divide  cases  of  empyema  antri  into  two  classes — one  in 
which  there  is  a  free  exit  for  pus  into  the  nose,  and  one  in 
which  the  ostium  maxillare  has  become  blocked. 

(«)  Abscess  with  jMient  Ostium  Ifaxillare. — Pain  is  by  no 
means  a  constant  or  marked  symptom.  It  may  be  quite 
absent,  or  maybe  referred  to  the  frontal  or  supra-orbital  region. 
Pain  in  the  malar  region  is  the  exception  in  these  cases. 
Swelling  of  the  cheek  is  seldom  present,  and  if  present 
probably  indicates  abscess  in  the  antrum  caused  by  dental 
cysts.  The  most  characteristic  symptom  is  an  intermittent 
discharge  of  pus  from  one  nostril  (excepting  in  the  rare 
cases  of  double  empyemata.).  The  periodicity  of  the  dis- 
charge is  explained  in  the  following  way.  When  the  patient 
lies  down  the  pus  trickles  backwards  to  the  pharynx,  but 
when  he  sits  up,  especially  with  the  head  inclined  to  the 
healthy  side,  the  pus  flows  from  the  nostril  corresponding  to 
the  antrum  affected.  Another  peculiarity  is  that  the  patient 
notices  a  distinctly  disagreeable  odour,  compared  to  rotten 
fish,  but  the  odour  is  not  perceived  by  other  people. 

An  important  consequence  of  an  unrecognised  empyema 
of  the  antrum  is  the  damage  done  to  the  digestive  organs 
by  the  constant  swallowing  of  purulent  fluid  during  sleep. 
Under  these  circumstances,  the  patient  is  always  ailing,  is 


148 


DISEASES    OF   THE   ANTRUM. 


unable  to  take  food  in  the  morning,  and  may  be  reduced  to< 
a  state  of  great  prostration,  even  dangerous  to  life.  The 
usual  remedies  for  indigestion  are  likely  to  be  of  little  service 
so  long  as  the  purulent  drain  continues. 

(&)  Abscess  with  Mocked  Ostium  Maxillare. — In  exceptional 
cases  the  pus,  not  finding  an  exit,  distends  the  antrum,  caus- 
ing partial  absorption  of  the  walls,  and  thus  both  bulging  out 
the  cheek  and  thrusting  up  the  floor  of  the  orbit.  Fig.  5  7 
shows  the  prominence   of  the   cheek   thus   produced  in   a, 

Yui.  57 


patient  under  the  care  of  Sir  William  Eergusson.  Under 
these  circumstances  the  affection  is  readily  recognised  by  the 
peculiar  crackling  which  is  perceived  when  the  thinned  bone 
is  pressed  upon,  and  the  matter,  if  not  evacuated,  will  shortly 
find  a  way  out  for  itself,  either  by  the  side  of  the  teeth, 
through  the  front  wall  of  the  antrum,  or  through  the  floor 
of  the  orbit ;  in  either  of  which  cases  considerable  necrosis 
and  ultimate  scar  are  likely  to  be  the  consequences. 

In  these  cases  pain  is  generally  a  prominent  symptom, 
especially  in  the  cheek,  and  fever,  occasionally  with  rigors, 
is  sometimes  present. 


EMPYEMA   ANTRI.  149 

The  elevation  of  the  floor  of  the  orbit  already  described 
may  simply  displace  the  eyeball  and  render  it  temporarily 
blind,  as  in  a  case  recorded  by  Mr.  J.  Smith,  of  Leeds 
{Lancet,  February  14,  1857),  or  it  may  lead  to  permanent 
amaurosis — a  point  to  which  Mr.  Salter  called  especial 
attention  in  the  Mcdico-Cliirurgical  Transactions  for  1862. 
Mr.  Salter's  patient,  a  young  woman,  twenty-four  years  of 
age,  was  attacked  with  violent  toothache  in  the  first  right 
upper  molar,  which  was  followed  by  enormous  swelling  of 
the  side  of  the  face  and  intense  pain.  The  eyeball  then 
became  protruded,  and  she  soon  after  perceived  that  the  eye 
was  blind.  Shortly  after  the  establishment  of  these  symp- 
toms, "  abscess  "  of  the  antrum  pointed  at  the  inner  and 
then  at  the  outer  canthus,  and  a  large  discharge  of  pus  at 
both  orifices  followed  ;  these  orifices  soon  closed,  but  the 
general  symptoms  of  the  part  continued  unchanged — the 
swelling  of  the  face,  protrusion  of  the  globe,  and  blindness. 
This  state  of  things  lasted  for  about  three  weeks,  when  the 
patient  was  sent  to  Guy's  Hospital,  and  admitted.  At  this 
time  the  patient  exhibited  hideous  disfigurement  from  swell- 
ing of  the  face,  oedema  of  the  lids,  and  lividity  of  the  sur- 
rounding integument.  Upon  examining  the  mouth,  it  was 
found  that  the  carious  remains  of  the  first  right  upper  molar 
appeared  to  be  associated  with  and  to  have  caused  the  dis- 
ease. Together  with  the  other  contiguous  carious  teeth, 
this  was  removed,  and  led  by  an  absorbed  opening  into  the 
floor  of  the  antrum.  The  haemorrhage  which  followed  the 
operation  was  discharged  partly  through  the  nose,  and  partly 
through  the  orifices  in  the  cheek,  as  well  as  from  the  tooth- 
socket,  showing  a  common  association  of  these  openings  with 
the  antrum.  The  condition  of  the  eye  constituted  the  most 
important  symptom,  and  the  most  distressing.  The  sight 
was  utterly  gene  ;  the  globe  prominent  and  everted.  There 
was  general  deep-seated  inflammation  of  the  fibrous  textures 
of  the  eye.  The  pupil  was  large  and  rigidly  fixed ;  it  did  not 
move  co-ordinately  with  the  other  under  any  circumstances. 
Some  abatement  of  the  symptoms  followed  the  extraction  of 
the  tooth  ;  but  it  was  soon  found  that  there  was  a  consider- 


150  DISEASES    OF  THE   ANTEUM. 

able  sequestrum  of  dead  Lone,  which  was  removed.  The 
necrosis  involved  the  front  part  of  the  floor  of  the  orbit,  the 
cheek  surface  of  the  superior  maxilla,  with  the  infra- orbital 
foramen,  and  a  large  plate  of  bone  from  the  inner  (nasal) 
wall  of  the  antrum.  The  removal  of  the  dead  bone  was 
followed  by  the  immediate  and  complete  cessation  of  all 
inflammatory  symptoms  ;  but  the  eye  remained  sightless, 
and  the  pupil  rigidly  fixed.  About  five  weeks  after  the 
removal  of  the  dead  bone,  it  was  noticed  that  the  pupil  of 
the  affected  eye  moved  with  that  of  the  other,  under  the 
influence  of  light,  though  vision  in  it  had  not  returned. 

Mr.  Charles  Gaine,  of  Bath,  has  recorded  (British  Medical 
Journal,  December  30,  1865)  a  very  similar  instance  in  a 
young  woman  of  twenty-two.  In  Mr.  Salter's  paper  will 
be  found  the  case  of  a  gentleman,  aged  thirty-five,  under  the 
care  of  Mr.  Pollock,  who  had  amaurosis  following  inflamma- 
tion without  abscess,  and  one  by  Dr.  Briick,  where  amaurosis 
followed  abscess,  in  the  person  of  a  man  of  forty-five.  Sir 
Thomas  Watson,  in  his  "  Lectures  on  Physic,"  alludes  also 
to  two  cases  of  temporary  amaurosis,  the  result  of  diseased 
teeth  in  the  upper  jaw. 

But  even  more  serious  results  have  followed  neglected 
suppuration  in  the  antrum,  for  Dr.  Mair,  of  Madras,  has 
recorded,  in  the  Edinhurgh  Medical  Joximal  for  1866,  the 
case  of  a  gentleman  in  whom  suppuration  in  the  antrum 
was  followed  by  death  in  sixteen  days,  from  suppuration 
within  the  cranium  accompanied  by  epileptic  convulsions. 

Bouhlc  Antral  Abscess. — The  possibility  of  both  antra  being 
affected,  either  simultaneously  or  consecutively,  must  not  be 
overlooked.  I  have  a  patient  now  under  my  care  whose  right 
antrum  1  emptied  some  years  back,  and  who  has  now  symp- 
toms which  point  to  the  presence  of  matter  in  the  opposite 
antrum,  and  Mr.  0.  Tomes  has  met  with  the  same  occurrence. 

Diagnosis. — Given,  a  patient  who  complains  of  purulent 
discharge  from  the  nostril,  with  occasionally  a  disagreeable 
smell,  and  the  case  is  too  apt  to  be  put  down  as  one  of 
ozsena,  and  treated  by  nasal  douches,  snuffs,  &c.  But,  as 
already  mentioned,  the  offensive  smell  is  perceived  only  by 


DIAGNOSIS    OF    EMPYEMA    ANTRI.  151 

the  patient,  and  not  by  his  friends,  the  reverse  being  the  case 
in  ozcena ;  and,  again,  the  discharge  is  only  occasional,  is 
determined  by  the  position  of  the  head,  and  is  simply 
purulent,  whereas  in  ozsena  the  discharge  is  constant,  and 
mixed  with  offensive  crusts  from  the  nasal  cavities.  Again, 
the  dull  ache,  varied  occasionally  by  acute  pain,  is  apt  to  be 
referred  to  the  teeth  alone,  and  the  most  careful  examination 
may  fail  to  detect  any  special  tenderness  in  any  one  tooth. 
Hence,  after  exhausting  the  usual  routine  remedies  for 
neuralgia,  I  have  known  wholesale  extraction  of  useful  teeth 
undertaken  with  no  benefit,  unless  it  should  fortunately 
happen  that  the  tooth  which  has  perforated  the  antrum 
should  be  extracted  early,  when  the  discharge  of  pus  at  once 
clears  up  the  nature  of  the  case. 

A  still  more  serious  result  may  ensue  if  the  neuralgia 
should,  as  it  often  does,  take  the  form  of  frontal  headache, 
and  thus  lead  the  surgeon  to  suppose  that  the  discharge 
comes  from  the  frontal  sinus.  I  have  twice  been  consulted 
on  cases  in  which  enterprising  surgeons  had  proposed  to  tre- 
phine the  frontal  sinus,  regardless  of  the  serious  injury  to 
the  patient's  good  looks,  for  chronic  discharge  which  I  proved 
to  be  solely  due  to  suppuration  in  the  antrum. 

There  are  certain  methods  by  which  the  presence  of  pus 
may  be  positively  determined. 

(«)  Position  of  Patient. — The  nasal  cavity  having  been 
carefully  cleaned,  the  patient  is  told  to  go  on  his  hands  and 
knees  and  to  hang  the  head  down,  inclining  it  away  from  the 
suspected  side.  By  this  means  pus  may  trickle  from  one 
nostril,  or  by  examination  with  a  speculum  some  pus  may  be 
seen  in  the  middle  meatus. 

(6)  Cathetcrisation  of  the  Ostium  Maxillarc. — According  to 
many  observers  this  is  a  very  difficult,  even  impossible 
proceeding.  It  has  been  mentioned  above,  however,  that 
Heryng  considers  it  a  simple  and  easy  method. 

(c)  Illumination  of  the  antra  by  means  of  an  electric  light 
held  in  the  mouth  is  considered  by  some  observers  to  be  very 
useful  in  diagnosis.  A  very  convenient  apparatus  for  this 
purpose  h::s  been  designed  by  Mr.  IST.  Stevenson.     Fig.  5  8 


152 


DISEASES    OF    THE  ANTEUM. 


shows  the  lamp  attached  to  a  vulcanite  plate,  which 
is  comfortably  gripped  by  the  teeth.  Undue  heating  of 
the  lamp  is  prevented  by  surrounding  it  by  a  glass  bulb 
through  which  air  can  freely  circulate.  By  means  of  a 
powerful  lamp  a  bright  reddish  yellow  light  is  thrown 
through  the  cheeks  and  lower  eyelids.  In  purulent  collec- 
tions in  the  antrum  a  diminution  in  the  amount  of  illumina- 
tion is  at  once  seen,  especially  in  the  intensity  of  the  light 
transmitted  through  the  lower  eyelid. 

(d)  If  these  methods  fail,  we  may  aspirate  the  antrum  in 
one  of  the  following  places  :  in  the  region  of  ostium  maxillare. 

Fig.  58. 


through  the  inferior  meatus  of  nose,  or  in  the  interval  between 
the  first  and  second  molar  teeth,  care  being  taken  to  avoid 
injuring  the  teeth.  The  great  objection  to  this  method  is  that 
inflammation  may  be  started  in  a  previously  healthy  antrum. 

Treatment. — The  first  indication  is  to  give  free  exit  to  the 
pus.  This  cannot  be  done  satisfactorily  through  the  ostium 
maxillare,  therefore  we  must  seek  another  way.  Two  methods 
suggest  themselves:  through  the  nose  and  through  the  mouth. 

The  Nasal  Boitte. — This  can  be  done  by  making  an 
artificial  opening  in  the  region  of  the  ostium  maxillare,  as 
recommended  by  Storck,  or  in  the  inferior  meatus  as 
recommended  by  Mickulicz. 

The  objections  to  this  method  are  that  it  is  impossible 


TREATMENT    OF    EMPYEMA    ANTRI.  153 

to  tap  the  most  dependent  part  of  the  cavity,  and  the 
hemorrhage  is  sometimes  very  free. 

The  Oral  Route. — In  many  cases,  as  we  have  seen,  the 
abscess  is  caused  by  a  decayed  molar  tooth.  If  this  be  the 
case,  the  tooth  should  be  extracted  and  the  antrum  opened 
by  boring  a  hole  through  the  tooth-socket.  If,  however,  the 
teeth  are  healthy,  or  but  slightly^ecayed^  it  is  better  to  tap 
the  antrum  just  above  the  alveolar  border. 

After  considerable  experience  of  both  methods  I  prefer 
the  puncture  above  the  alveolus,  except  when  a  tooth 
obviously  requires  extraction,  because  I  find  that  the  aperture 
is  less  liable  to  close  up  than  when  made  through  the 
alveolus,  and  because  food  is  less  likely  to  find  its  way  into 
the  antrum.  It  is  necessary,  however,  not  to  direct  the 
trocar  quite  horizontally  but  a  little  upwards,  lest  in  a  case 
•of  highly  arched  palate  the  floor  of  the  antrum  should  be 
injured,  as  I  have  known  on  one  occasion,  but  then  fortu- 
nately with  no  permanent  damage,  except  the  exfoliation  of 
a  minute  portion  of  the  palate. 

Whatever  method  may  be  adopted  for  emptying  the 
antrum,  it  is  important  that  the  cavity  should  be  thoroughly 
cleansed  by  the  forcible  injection  of  warm  antiseptic  lotion 
until  it  runs  freely  from  the  nostril.  For  this  purpose  an 
ordinary  glass  syringe  is  quite  insufficient,  but  I  have 
satisfactorily  employed  an  ordinary  Eustachian  catheter  for 
the  purpose,  to  which  an  india-rubber  injecting-bottle  is 
adapted.  After  a  time,  and  with  a  little  instruction,  patients 
can  learn  to  dispense  with  the  syringe  by  forcing  a  mouthful 
■of  lotion  through  the  antrum  by  the  action  of  the  buccinator 
muscles.  After  thoroughly  cleansing,  some  antiseptic  and 
slightly  astringent  lotion  should  be  injected,  to  restore  the 
healthy  condition  of  the  mucous  membrane,  and  for  this 
purpose  weak  solutions  of  permanganate  of  potasli  or  sulphate 
of  zinc  answer  admirably ;  but  these  cases  are  exceedingly 
tedious,  as  a  rule,  and  take  many  months  for  their  cure.  If 
the  perforation  has  been  made  through  the  socket  of  a  tooth, 
care  must  be  taken  that  particles  of  food  do  not  gain  admis- 
sion to  the  antrum,  and  this  may  be  accomplished  by  plugging 


154  DISEASES    OF    THE    ANTEUM. 

the  hole  with  cotton  wool,  or,  as  suggested  by  Salter,  by 
fitting  a  metal  plate  to  the  mouth  with  a  small  tube  to  fill 
the  aperture,  which  can  be  corked  at  pleasure,  and  will  serve 
as  a  pipe  for  injection. 

It  is  very  important  that  the  opening  of  the  antrum  into 
the  nose  be  patent.  If  the  ostium  maxillare  is  blocked  the 
artificial  opening  into  the  antrum  will  not  close.  In  such 
cases,  if  the  ostium  maxillare  cannot  be  probed,  an  opening 
should  be  made  from  the  nose  into  the  antrum,  in  the  region 
of  the  ostium  or  through  the  inferior  meatus. 

In  favourable  cases  the  opening  made  into  the  antrum 
through  the  mouth  closes  within  a  few  weeks,  but  sometimes 
the  sinus  persists  for  months  or  even  years.  The  treatment 
of  these  chronic  cases  will  be  considered  under  the  subject  of 
fistulae  of  the  antrum. 

The  possible  subdivision  of  the  floor  of  the  antrum  by 
bony  septa,  already  described,  must  be  borne  in  mind  in 
operating  upon  this  cavity,  and  especially  if  there  is  reason 
to  suspect  the  presence  of  any  foreign  body  which  may  be 
keeping  up  irritation.  In  his  paper  already  referred  to, 
Mr.  Cattlin  narrates  the  case  of  the  fang  of  a  tooth  lodging 
in  one  of  these  subdivisions,  from  which  it  was  extracted 
with  difficulty. 

Suppuration  in  the  antrum  may  assume  a  more  chronic 
form  than  that  above  described,  and  from  the  slow  expansion 
of  the  jaw  which  results  may  be  mistaken  for  a  solid  growth. 
Weber  describes  a  form  of  chronic  sub-periosteal  abscess 
proceeding  from  a  tooth,  which  is  surrounded  by  an  osseous 
plate  or  shell  formed  from  the  periosteum,  while  it  is 
separated  from  the  antrum  by  the  maxillary  wall  itself ;  and 
believes  that  the  occurrence  of  suppuration  commencing  in 
the  bone,  either  from  this  cause  or  from  the  suppuration  of 
a  dentigerous  cyst,  is  much  more  common  than  in  the  antrum 
itself,  but  in  this  I  do  not  agree,  though  recognising  the 
occasional  occurrence  of  the  form  of  abscess  described.  The 
diagnosis  of  these  several  forms  of  abscess  is  by  no  means 
easy,  and  errors  have  been  made  by  excellent  surgeons  in 
mistaking  them   for  solid   growths :  thus,   Listen   mentions 


EXPANSION    OF    THE    ANTRUM.  155 

("Practical  Surgery,"  p.  303)  having  seen  a  surgeon  have 
his  hands  covered  with  purulent  matter  in  attempting  to 
remove  a  supposed  tumour  of  the  jaw.  This  is  more 
especially  likely  to  happen  when,  as  is  sometimes  the  case, 
considerable  hypertrophy  of  the  osseous  wall  has  taken  place 
in  consequence  of  the  irritation  the  bone  has  been  subjected 
to.  Stanley  (p.  285)  mentions  a  case  of  the  kind  which 
occurred  in  the  practice  of  Sir  W.  Lawrence  :  "A  woman, 
aged  twenty-four,  was  admitted  with  a  large,  hard,  round 
swelling  of  the  cheek  in  the  situation  of  the  antrum ;  it  was 
free  from  pain,  and  the  soft  parts  covering  it  were  healthy ; 
such  was  the  solidity  and  hardness  of  the  swelling  that  it 
was  supposed  that  it  might  be  an  osseous  growth  from  the 
antrum,  and  the  history  appeared  to  confirm  this  view  of  its 
nature,  as  the  woman  stated  that  about  five  months  pre- 
viously she  had  received  a  blow  on  the  cheek,  and  that  soon 
afterwards  the  swelling  commenced,  and  had  slowly  increased 
to  its  present  magnitude,  which  was  about  that  of  a  middle- 
sized  orange.  A  scalpel  was  thrust  into  the  tumour  imme- 
diately above  the  sockets  of  the  molar  teeth,  and  healthy 
pus  flowed  from  the  opening ;  the  discharge  continued 
in  gradually  decreasing  quantity,  and  the  swelling  subsided 
as  the  walls  of  the  antrum  receded  to  their  natural 
limits." 

This  thickening  of  the  bone  may  remain  permanently, 
long  after  the  cure  of  the  abscess,  and  may  necessitate 
operative  interference  :  thus,  in  1850,  Sir  William  Fergusson 
met  with  a  case  of  osseous  tumour  of  the  size  of  a  pigeon's 
egg,  projecting  from  the  superior  maxilla  of  a  man,  aged 
fifty,  who  had  been  the  subject  of  abscess,  and  whose  antrum 
was  still  distended,  though  containing  no  fluid.  Here  it  be- 
came necessary  to  remove  the  tumour  with  the  anterior  wall 
of  the  antrum,  by  which  the  deformity  was  quite  got  rid  of. 
The  case  will  be  found  in  the  Lancet,  June  29th,  1850.  A 
case,  under  the  care  of  Mr.  Henry  Smith,  in  which  an 
abscess  consequent  on  necrosis  of  a  portion  of  the  jaw  closely 
simulated  a  tumour  of  the  antrum,  will  also  be  found  in  the 
British  Medical  Journal,  March  2nd,  1867. 


156  DISEASES    OF    THE    ANTRUM. 

2.  Fistulce  of  the  Antrum. — These  vary  considerably  in 
position,  and  may  be  divided  into  two  classes. 

(a)  Fistulse  opening  on  to  the  surface  of  the  face,  generally 
in  some  part  of  the  cheek,  or  just  below  the  lower  eyelid. 

(&)  Eistulse  opening  into  the  mouth,  either  through  the 
alveolar  process,  or  just  above  the  alveolar  process,  or  through 
the  hard  palate. 

Etiology. — Spontaneous  fistulcc  are  those  resulting  from  the 
bursting  of  an  abscess  of  the  antrum.  In  these  cases  the 
sinus  is  generally  situated  in  the  region  of  the  cheek  or 
lower  eyelid.  It  may,  however,  lead  from  the  antrum  on  to 
the  hard  palate,  or  on  to  the  alveolar  process. 

Sid-gical  fistidm  are  the  result  of  opening  the  antrum  for 
the  purpose  of  drainage,  and  are  generally  situated  in  the 
alveolar  process  or  in  the  canine  fossa. 

Tramnatic  fistulm  may  result  from  various  causes.  Frac- 
tures of  the  upper  jaw  and  gunshot  wounds  of  the  face  may 
be  followed  by  fistul^e.  Sometimes  the  antrum  is  opened 
when  extracting  a  tooth. 

Symptoms. — There  are  three  characteristic  symptoms : 
the  passage  of  air  from  the  fistula  when  the  patient  sneezes 
or  blows  his  nose,  the  passage  into  the  nose  of  fluids  in- 
jected into  the  sinus,  and  the  escape  of  pus  into  the  mouth. 
Tlie  pus  may  vary  both  in  quantity  and  odour.  As  a  rule  it 
does  not  smell  much,  and  is  scarcely  noticed  by  persons  other 
than  the  patient.  In  some  cases,  however,  when  the  drain- 
age is  not  free,  putrefaction  may  take  place  to  a  considerable 
extent,  and  cause  a  markedly  foetid  odour. 

It  must  be  remembered  that  the  first  two  symptoms  are 
absent  when  the  ostium  maxillare  is  blocked.  In  these 
cases  the  introduction  of  a  probe  through  the  fistula  into  the 
antrum  clears  up  any  doubt  in  the  diagnosis. 

Treatment.— The  chief  indications  are  to  obtain  perfect 
drainage  for  the  pus,  and  to  treat  the  suppurating  mucous 
membrane  with  antiseptic  and  stimulating  lotions.  In  the 
case  of  the  cutaneous  fistul?e  it  is  important  to  make  another 
opening  into  the  antrum  from  below  through  the  mouth,  so 
that  the  drainage  shall  be  perfect.     The  cutaneous  fistula 


CYSTIC    DISEASE    OF    THE    ANTRUM.  157 

will  then  rapidly  heal.  Sometimes  it  is  very  difficult  to  get 
a  fistula  opening  into  the  mouth  to  close  up.  In  these  cases 
the  cavity  of  the  antrum  might  be  scraped  with  a  small 
curette,  so  as  to  remove  any  unhealthy  granulation  tissue. 
In  spite  of  all  treatment,  however,  some  of  these  fistulas 
refuse  to  heal. 

3.  Cystic  disease  of  the  antrum,  sometimes  and  erroneously 
termed  "  hydrops  antri"  or  "  dropsy  of  the  antrum,"  is  a 
disease  which  has  long  been  recognised,  though,  within  the 
last  few  years,  opinions  have  changed  as  to  the  exact  pathology 
of  the  affection.  The  history  of  these  cases  is  one  of  gradual, 
painless  dilatation  of  the  upper  jaw,  until  its  outer  wall  be- 
comes so  thin  as  to  crackle  like  parchment  upon  pressure 
being  made,  or  at  certain  points  being  so  absorbed  that 
fluctuation  is  readily  perceptible.  Occasionally  the  other 
walls  of  the  jaw  yield,  though  more  slowly,  to  the  persistent 
pressure,  the  palate  becoming  flattened,  and  the  nostril 
blocked  by  the  bulging  of  the  internal  wall.  On  the  ex- 
traction of  a  molar  tooth  and  perforation  through  its  socket,. 
as  described  under  the  previous  section,  or  more  frequently 
by  an  incision  through  the  osteo-membranous  wall  of  tha 
cyst,  a  quantity  of  clear  or  yellowish  serous  fluid  is  evacu- 
ated, which  frequently  contains  flakes  of  cholesterine  floating 
in  it.  After  the  evacuation  of  the  fluid  the  swelling  ordi- 
narily  subsides,  the  maxilla  resuming  its  normal  relations,  and 
the  opening  closing. 

The  old  explanation  of  these  phenomena  was,  that  the 
aperture  between  the  antrum  and  the  nostril  having  become 
accidentally  obstructed,  the  mucous  secretion,  which  was 
presumed  to  be  constantly  taking  place  within  the  cavity,  was 
thought  to  be  imprisoned,  and,  by  its  gradual  accumulation,, 
to  produce  the  symptoms  which  have  been  described.  Fol- 
lowing up  this  idea,  we  find  surgeons,  and  among  others 
Jourdain,  of  Paris  (1765),  who  very  accurately  described 
the  affection,  recommending  the  restoration  of  the  nasal 
orifice  by  probing  (see  Guerin's  EUriiens  de  Chirurgie 
OpSratoire,  1855).  Bordenave,  in  his  "Observations  on 
Diseases  of  the  Maxillary  Sinus  "  (Sydenham  Society's  trans- 


158  DISEASES    OF    THE    ANTRUM. 

lation,  1848),  gives  full  details  of  this  method  of  probing 
and  injecting,  but,  after  showing  that  there  is  great  dithculty 
and  uncertainty  in  finding  the  natural  orifice,  remarks  that 
*'  there  are  very  few  cases  in  which  the  employment  of  in- 
jections through  the  natural  openings,  in  the  manner  above 
described,  would  effect  a  complete  cure."  It  is  certain, 
however,  that  some  of  these  cases,  and  very  probably  all  of 
them,  originate  in  the  growth  of  a  cyst,  or  cysts,  within  the 
antrum,  or  more  commonly  in  the  wall  of  the  antrum,  which 
either  grow  to  such  a  size  as  to  be  mistaken  for  the  cavity 
of  the  antrum  when  opened,  or  break  into  the  antrum  by 
absorption  of  the  cyst-wall,  so  that  on  subsequent  examination 
no  evidence  of  cyst  formation  can  be  discovered.  This 
explanation  is,  as  pointed  out  by  Coleman,  supported  by  the 
fact  that  in  these  cases  of  so-called  liydrops  cmtri,  the  con- 
tained fluid  in  no  respect  resembles  ordinary  mucus,  but  is 
invariably  a  clear,  more  or  less  yellow  fluid,  frequently  con- 
taining cholesterine  in  considerable  quantity.  In  these 
respects  it  closely  resembles  that  found  in  well-marked  cases 
of  cystic  growth,  which  have  been  examined  in  various  stages 
of  development. 

A  remarkable  case  of  distension  of  the  antrum  is  narrated 
by  Sir  William  Tergusson,  and  the  preparation  is  preserved 
in  the  King's  College  Museum.  It  was  taken  many  years 
ago  from  a  subject  in  the  dissecting-room,  and  from  the 
person  of  an  old  woman.  The  tumour,  w^hicli  was  of  very 
large  size,  had  burst  shortly  before  death,  leaving  the 
remarkable  deformity  shown  in  Fig.  59  (taken  by  permission 
from  Sir  W.  Fergusson's  work  on  Surgery),  which  is  due 
to  the  complete  absorption  of  the  front  wall  of  the  antrum 
and  its  collapse,  by  which  a  prominent  horizontal  ridge  of 
bone,  formed  by  the  upper  wall  of  the  antrum,  has  been  left 
immediately  below  the  orbit.  The  preparation  shows  great 
distension  of  the  antrum,  the  diameter  of  which  varies  in 
difierent  parts  from  two  to  two  and  a  half  inches,  and  the 
bony  wall  is  so  thinned  out  as  to  resemble  parchment.  The 
gums  are  edentulous.  There  is  no  communication  between 
the   nose  or  mouth  and  the  cavitv,  which  is  lined  with  a 


CYSTIC    DISEASE    OF    THE    ANTKUM. 


159 


membrane  covered  with  laminated  deposit.  (For  these 
particulars  I  am  indebted  to  iJr.  Trimen,  the  late  curator.) 
Whether  this  was  originally  a  case  of  cystic  growth,  or  a 
chronic  abscess,  it  is  impossible  now  to  decide,  but  it  is,  so 
far  as  I  am  aware,  a  unique  post-mortem  specimen  of  this 
distension. 

Numerous  instances  of  so-called  distension  of  the  antrum 
by  clear  fluid  in  living  patients,  have  been  recorded  from 
time  to  time,  and  occasionally  mistakes  have  been  made  by 


the  surgeon  in  regarding  the  tumour  as  of  a  solid  nature. 
A  very  remarkable  case,  in  which  a  distended  antrum  closely 
simulated  a  solid  growth,  occurred  in  the  practice  of  Sir 
William  Fergusson,  and  the  details  of  the  case  will  be 
found  in  the  Lancet,  June  29th,  1850.  Here  the  surgeon 
made  an  exploratory  puncture  before  commencing  the  more 
serious  operation  ;  but  a  case  has  occurred  within  my  own 
knowledge,  in  which  a  very  able  surgeon  removed  the  upper 
jaw  before  discovering  the  error  of  his  diagnosis. 

M.  Giraldes  would  appear  to  have  been  the  first  author 
upon  the  subject  of  cysts  of  the  antrum,  and  his  thesis 
gained  the  Montyon  prize  in  1853;  but  Mr.  W.  Adams  may 


160  DISEASES    OF    THE   AXTKUM. 

fairly  claim  priority  of  investigation,  as  shown  by  specimens 
preserved  in  St.  Thomas's  Museum — as  indeed  is  acknow- 
ledged by  M.  Giraldes.  Luschka  subsequently  investigated 
the  subject,  and  in  sixty  post-mortem  examinations  found 
cystic  growths  in  the  antrum  five  times,  some  of  them  being 
two  centimetres  in  length.  A  careful  examination  of  the 
antra  of  thirty  subjects,  made  for  me  by  the  late  Mr.  Marcus 
Beck,  then  Demonstrator  of  Anatomy  of  University  College, 
during  the  winter  of  1867-68,  failed  to  discover  an  instance 
of  the  kind. 

Mr.  Adams'  specimens,  from  one  of  which  the  drawing-; 
(Fig.  60)  was  made,  show  each  a  cyst  of  oval  outline,  attached 
to  the  inner  wall  of  the  antrum,  and  measuring  rather  more 
than  an  inch  and  three-quarters  of  an  inch  respectively,  in 
their  long  diameters.  These,  of  course,  are  too  small  to- 
have  produced  auy  symptoms  during  life.  The  specimens 
given  by  M.  Giraldes  in  his  Bechcrclics  sur  Ics  Kystes 
Mvjpieuoi  du  Sinus  Maxillaire  from  one  of  which  the 
illustration  (Fig.  6 1 )  is  taken,  show  very  varying  degrees  of 
cystic  growth  in  the  mucous  membrane  of  the  antrum.  In 
one  instance  there  is  a  single  cyst  at  the  floor  of  the  antrum,, 
into  which  an  opening  has  been  made,  whilst  in  the  others 
the  cysts  are  very  numerous  and  of  very  variable  sizes, 
depending,  apparently,  upon  a  cystic  degeneration  of  the 
entire  mucous  membrane.  M.  Giraldes  explains  the  forma- 
tion of  these  cysts  as  being  due  to  the  dilatation  of  the 
glandular  follicles  of  the  mucous  membrane,  and  urges  that 
the  ordinary  operation  of  tapping  the  antrum  would  be 
useless  in  such  cases,  but  that  it  would  be  necessary  to  open 
up  the  antrum,  so  as  to  get  at  the  seat  of  the  disease. 
Fortunately  these  numerous  cysts  appear  to  be  of  slower 
growth  than  the  single  cysts,  for  it  would  be  impossible  to 
extirpate  such  numbers  as  are  here  seen  (Fig.  60),  without 
removing  the  entire  jaw. 

The  contents  of  these  cysts  appear  to  be  at  first  clear 
fluid,  but  of  a  viscid  nature ;  when  more  fully  developed, 
the  fluid  becomes  flaky,  from  the  presence  of  cholesterine, 
and    occasionally   assumes   a   greenish   tint.      It    may   also 


CYSTS    OF    THE    ANTIIUM. 


161 


become  purulent,  and  Maisonneuve  has  recorded  (Gazette  des 
Hopitaux,  January  6tli,  1855)  a  case  where  pressure  on  tlie 


Fig.  60. 


cheek  produced  a  flow  of  butter-like  fluid  from  the  nose  in 
a  young  woman  who,  for  a  year,  had  suffered  from  a  tumour 


of  the  right  upper  jaw,  which  had  been  pronounced  malig« 
nant,  the  face  being  enlarged  and  the  nostril  obstructed. 
Here  puncture  from  the  nostril,  combined  with  pressure  and 

L 


162  DISEASES    OF    THE   ANTEUM. 

injections,  effected  a  cure,  and  the  case  must  be  considered 
as  one  of  cyst  of  tlie  antrum,  but  whether  a  mucous  cyst,  the 
contents  of  which  had  undergone  solidification,  or  a  separate 
formation,  must  remain  doubtful. 

Treatment, — The  treatment  of  cystic  disease  of  the  jaw 
is  generally  sufficiently  simple.  The  bony  wall  being  most 
commonly,  to  some  extent,  absorbed,  it  is  only  necessary  to 
incise  the  distended  membrane  and  evacuate  the  fluid.  The 
finger  then  passes  readily  into  the  cyst  and  can  examine  its 
interior,  searching  for  any  growth  or  tooth  which  may  be 
lodged  within.  With  curved  scissors  the  opening  can  then 
be  enlarged  by  cutting  away  the  membranous  wall  suffi- 
ciently to  allow  a  free  passage  for  any  discharge.  The  use 
of  a  simple  stimulating  lotion  with  a  syringe  is  then  all 
that  is  required  to  effect  a  cure,  which,  though  slow,  is 
permanent.  I  have  treated  a  considerable  number  of  cases 
of  cyst  of  the  jaw  in  this  manner,  and  with  uniformly  good 
results. 

Broca  (Tumeurs,  vol.  ii,  p.  37)  recommends  to  remove 
the  membrane  covering  the  inner  wall  of  the  cyst,  and  gives 
a  case  in  which  Nelaton  discovered  a  plate  of  bony  tissue 
derived  from  a  malformed  tooth  on  the  inner  aspect  of  a 
cyst,  but  this  is  in  most  cases  a  quite  unnecessary  complica- 
tion of  what  is  usually  a  very  simple  matter. 

4.  Tumours  of  the  Antrum. — These  are  by  no  means 
common,  and  may  be  conveniently  divided  into  two  classes, 
the  simple  and  the  malignant. 

Simple  Tumours  of  the  Antrum. — With  the  exception  of 
polypi,  simple  tumours  are  very  rarely  met  w^ith. 

Polypus  of  the  Antrum. — This  is  not  a  common  affection, 
though  by  no  means  so  very  rare  as  stated  by  Paget. 
Luschka  has  investigated  the  subject  (Virchow's  Archiv,. 
Bd.  viii,  p.  419),  and  found  polypi  five  times  in  sixty  sub- 
jects, some  being  two  centimetres  in  length.  He  gives  a 
drawing,  showing  a  large  number  of  these  polypoid  growths  in 
an  antrum,  which  he  considers  to  be  hypertrophies  of  the  sub- 
mucous connective  tissue,  covered  with  mucous  membrane. 
Billroth  also  describes  a  good  example  of  large  polypus  of 


POLYPI    OF    THE    ANTKUM.  1G3 

the  antrum  with  a  long  pedicle,  and  regards  it  as  a  very 
rare  affection,  and  there  is  a  good  specimen  in  University 
College  Museum. 

These  polypi  are  closely  allied  apparently  to  the  small 
cystic  growths  in  the  mucous  membrane  of  the  antrum, 
described  by  Giraldes.  Both  affections  consist  essentially  in 
hypertrophy  of  some  elements  of  the  mucous  and  submucous 
tissues.  When  the  connective  or  areolar  tissue  predominates, 
the  fleshy  polypus  is  produced  ;  when  the  glandular  element 
is  especially  affected  we  have  the  cystic  form  produced. 
Intermediately,  when  the  fibrous  element  is  very  loose  and  we 
have  some  glandular  hypertrophy,  the  semi-gelatinous  poly- 
pus is  produced,  which  closely  resembles  the  nasal  polypus. 

Polypi  of  the  antrum  are  well  supplied  with  blood-vessels, 
and  bleed  freely  when  interfered  with.  In  some  instances 
they  appear  to  have  a  malignant  character,  or  at  least  are 
the  forerunners  of  malignant  disease  occurring  in  the 
antrum  and  jaw.  Vidal  de  Cassis,  who  {Traite  de  Pathologic 
Externe,  torn,  iii,  p.  492)  totally  denies  the  existence  of 
any  true  polypoid  growths  in  tbe  antrum,  says  that  what 
have  been  mistaken  for  them  most  frequently  are  colloid 
tumours  of  the  periosteum,  but  believes  that  many  of  the 
cases  are  examples  of  cystic  growth.  Syme  also,  following  the 
example  of  John  Bell,  maintains  that  polypi  in  the  antrum 
always  intrude  from  the  nose,  and  are  never  developed  in 
the  antrum  itself  {Lancet,  May  10,  1855). 

Sir  James  Paget  has  put  on  record  {Clinical  Soc.  Trans., 
xii)  a  case  of  polypus  of  the  antrum  in  which  a  constant 
flow  of  clear  watery  fluid  from  the  nose  was  the  only 
symptom.  At  the  post-mortem  examination  "  the  floor  of 
the  antrum  was  covered  with  two  broad-based  convex  poly- 
poid growths,  deep  clear  yellow  with  the  fluid  infiltrated  in 
their  tender  tissue,  and  covered  with  exceedingly  thin  smooth 
membrane  traversed  by  branching  blood-vessels.  They  were 
of  rounded  shape,  about  two-thirds  of  an  inch  in  diameter, 
and  half  an  inch  in  depth  ;  they  looked  like  very  thin-walled 
cysts,  but  were  formed  of  very  fine  membranous  or  filamen- 
tous tissue,  infiltrated  with  serum." 


164  DISEASES    OF   THE    ANTRUM. 

Ordinarily  the  symptoms  of  polypi,  no  less  than  of  cysts 
of  the  antrum,  only  become  developed  when  the  growth  is 
of  sufficient  size  to  encroach  upon  the  neighbouring  cavities, 
or  produce  distension  and  absorption  of  the  front  of  the 
antrum.  The  most  common  situation  for  the  polypus  to 
show  itself  is,  as  might  be  expected,  the  nose,  since  the 
tumour  readily  induces  absorption  of  the  thin  nasal  wall  of 
the  antrum.  Here  it  closely  resembles  the  ordinary  nasal 
polypus,  and  Sir  William  Fergusson  mentions  ("  Practical 
Surgery,"  p.  561)  two  cases  of  the  kind  in  which  this  had 
occurred,  one  being  in  his  own  practice.  In  that  instance 
he  soon  found  that  he  had  attacked  a  tumour  of  the  antrum, 
which,  in  consequence  of  its  deep  and  firm  attachment,  and 
the  great  haemorrhage  attending  it,  he  did  not  entirely 
remove.  The  disease  returned,  and  he  again  operated,  on 
this  occasion  using  great  force,  and  wrenched  out  the  whole 
mass,  not  without  some  fear  of  the  consequences.  The  case, 
however,  did  well,  and  after  ten  years  the  disease  had  not 
returned. 

In  the  Mediccd  Times  and  Gazette,  March  i  8th,  i860,  is  a 
report  of  another  case  in  which  the  same  surgeon  removed 
a  vascular  fibrous  polypus  of  the  antrum  which  had  pro- 
jected into  the  nostril,  by  laying  open  the  front  wall  of  the 
cavity,  and  with  strong  forceps  tearing  out  the  tumour  bit 
by  bit. 

I  had,  during  1866,  the  opportunity  of  watching  the 
case  of  a  patient  who  had  had  a  polypus  partially  removed 
by  the  nose  on  several  occasions,  and  from  whom  Mr. 
Holthouse  removed  an  entire  growth  a  year  and  a  half 
before  that  date.  He  reappeared  with  a  swelling  of  the 
jaw,  evidently  due  to  distension  of  the  antrum  by  some  soft 
growth,  and  he  had  also  a  soft  tumour  on  the  forehead. 
These  were  doubtless  cancerous,  for  his  strength  failed, 
and  he  sank  after  some  months,  but  unfortunately  his 
relations  would  not  permit  a  post-mortem  examination  to 
be  made. 

Hypertrophy  of  the  glandular  tissue  of  the  mucous 
membrane    appears    capable    of    producing    tumours    of    a 


FALLING    IN    OF    THE   ANTRUM.  165 

friable  description,  which  may  fill  up  the  antra  on  both 
sides,  as  in  a  case  recorded  by  M.  Demarquay  {Gazette 
MM'icalc  clc  Paris,  November  4th,  1857).  Here  the  patient 
had  a  large  tumour  on  each  side  of  the  nose,  the  passages 
of  which  were  completely  obstructed,  and  his  right  eye  was 
protruded  from  the  orbit.  M.  Demarquay  removed,  the 
front  walls  of  the  antra,  and  extirpated  two  masses  of  very 
friable  tissue  of  a  greyish-white  colour,  in  which  the  vas- 
cular tissue  was  not  abundant.  M.  Eobin,  who  examined 
the  growths,  pronounced  them  to  be  the  result  of  an  hyper- 
trophy of  the  glandular  element  of  the  mucous  membrane 
of  the  antrum. 

A  curious  and,  I  believe,  unique  case  of  falling  in  of 
the  antrum,  recorded  by  Mr.  "White  Cooper,  may  be  con- 
veniently mentioned  here,  since  the  depression  of  the  wall 
of  the  cavity  depended,  no  doubt,  upon  some  alteration 
going  on  in  its  interior — possibly  the  absorption  of  some 
Huid  which  had  previously  induced  thinning  of  the  bones. 
The  patient  was  brought  before  the  Medical  Society  of 
London  in  185  i,  and  Mr.  Cooper  has  kindly  given  me  the 
following  details  of  her  case : 

"  I  first  saw  Margaret  Eyan  (aged  twenty-seven)  May 
22nd,  1849. 

"  Complained  of  the  tears  running  over  the  left  cheek, 
first  perceived  about  a  week  previously. 

''  Seven  years  ago  first  observed  a  black  mark  round  the 
lower  part  of  the  left  eye-lid  ;  without  pain,  weakness  of 
eye  or  toothache.  Gradually  and  almost  imperceptibly 
flattening  of  the  cheek  came  on. 

"  The  appearance  presented  was  that  of  a  deep  depression 
between  the  malar  bone  and  nose,  precisely  as  if  a  portion 
of  the  superior  maxillary  bone  had  been  cut  away. 

"  It  was  bounded  superiorly  by  the  inferior  margin  of  the 
orbit,  which  partook  of  the  depression  ;  inferiorly  by  the 
base  of  the  alveolar  process  ;  and  externally  by  the  malar 
bone.  As  compared  with  the  other  cheek,  the  dimensions 
were  as  follows :  From  bridge  of  nose  over  deepest 
point    of    depression,  one  inch    four-tenths,    or    nearly    an 


166  DISEASES    OF    THE    ANTEUM. 

inch  and  a  half  ;  right  side  to  corresponding  point  just  one 
inch. 

"  There  was  a  peculiar  dusky  hue  about  the  depression, 
especially  towards  the  upper  part.  The  cuspid  and  bicuspid 
teeth  were  removed  with  considerable  difficulty,  the  roots 
showing  thickening  of  periosteum. 

"  No  change  was  visible  at  the  expiration  of  twelve 
months." 

Fibroma  of  the  Antrum.  —  A  few  cases  of  fibromata 
originating  in  the  wall  of  the  antrum  and  projecting  into 
its  interior  have  been  recorded.  They  vary  considera.bly  in 
structure.  Some  are  quite  firm,  consisting  of  dense  fibrous 
tissue  ;  others  are  more  vascular,  presenting  a  somewhat 
cavernous  structure;  and  others  again  may  be  calcified  in 
places,  especially  in  their  centre.  They  will  be  considered 
at  greater  length  in  connection  with  simple  tumours  of  the 
upper  jaw. 

Encliondroma  of  the  Antrum. — These  are  occasionally  met 
with  arising  in  connection  with  the  periosteum  lining  the 
antrum.  Only  one  case  of  pure  enchondroma  has  been 
described,  but  mixed  tumours  containing  fibrous  or  calcified 
tissue  with  the  cartilage  are  more  common.  They  will  be 
considered  again  later  on. 

Osteoma  of  the  Antrum — Osseous  tumours  arising  in  the 
wall  of  the  antrum,  and  projecting  either  into  its  cavity  or 
towards  the  exterior,  are  occasionally  met  with.  They  may 
lie  loosely  in  the  cavity  of  the  antrum  or  may  be  connected 
to  the  wall  by  a  pedicle.  Sometimes  they  are  attached  by 
a  broad  and  firm  base  to  the  bony  wall.  They  will  be 
more  conveniently  considered  in  the  chapter  on  simple 
tumours  of  the  upper  jaw. 

Malignant  Tumours  of  the  Antrum. — These  are  more 
frequently  met  with  than  the  simple  tumours,  and  consist  of 
epitheliomata  and  sarcomata,  of  which  the  former  are  the 
more  common. 

Epithelioma  of  the  Antrum. — There  are  two  varieties  of 
this  disease ;  one  in  which  the  growth  originates  in  the 
lining  membrane  of  the  antrum,  primary  epitlulioma,   and 


EPITHELIOMA    OF   THE    ANTRUM.  167 

one  in  which  the  growth  invades  the  antrum  from  some 
neighbouring  part,  generally  from  the  palate  or  neighbour- 
hood of  the  teeth,  secondary  cpitlidioma.  The  former 
variety  is  very  seldom  met  with  ;  it  forms  very  vascular 
tumours  of  a  villous  nature,  gradually  distending  the  antrum 
and  finally  perforating  the  alveolar  border  of  the  jaw.  The 
lining  membrane  of  the  antrum  is  composed  of  cells  of  two 
kinds,  columnar  epithelium  cells,  many  of  which  are  ciliated, 
and  glandular  cells,  somewhat  goblet-shaped,  which  produce 
the  natural  secretion  contained  in  the  antrum.  Correspond- 
ing with  this  variety  in  the  structure  of  the  cells  lining 
the  antrum,  we  find  a  difference  in  the  malignant  growths 
that  originate  in  this  membrane.  One  kind  of  growth  is 
composed  of  columnar  cells,  or  cells  resembling  them,  and  is 
therefore  called  a  columnar  epithelioma  ;  the  other  kind  is 
composed  of  glandular  cells,  and  is  consequently  termed  a 
spheroidal-celled  or  glandular  carcinoma. 

Secondary  epithelioma  of  the  antrum  is  usually  of  the 
squamous  variety.  It  is  a  very  insidious  disease,  which 
gives  rise  to  the  formation  of  no  tumour  of  the  face,  but 
slowly  destroys  the  antrum  and  spreads  thence  in  all 
directions.  It  was  first  described,  from  the  clinic  of 
M.  Verneuil,  by  M.  Eeclus  {Pr ogres  MScUcal,  1876),  who 
termed  it  very  aptly  Spithdioma  Urdhrant  (burrowing  or 
boring  epithelioma),  and  attention  was  called  to  it  by  Mr. 
Butlin  in  1881.  I  had  at  the  time  two  cases  of  the 
kind  under  observation,  one  in  hospital,  which  was  at  first 
thought  to  be  epithelioma  of  the  palate,  but  in  which  the 
antrum  was  found  extensively  affected ;  and  the  other  in 
private,  which  was  a  good  typical  example  of  the  disease. 
The  patient,  aged  sixty-six,  had  a  troublesome  and  loose 
upper  molar  tooth,  for  which  he  consulted  a  well-known 
dental  surgeon  in  the  West  of  England,  who  extracted  it, 
bringing  away  a  soft  growth  attached  to  the  fangs.  The 
opening  was  found  to  communicate  with  the  antrum,  and 
shortly  a  fungus  growth  protruded,  and  there  was  a  good 
deal  of  discharge.  The  case  was  regarded  as  one  of  disease 
of  the  antrum,  which  was  well  syringed  out,  but  the  palate 


168  DISEASES    OF   THE   ANTKUM. 

became  more  involved  and  the  cheek  somewhat  swollen. 
When  I  saw  the  patient  in  September,  1 8  8 1 ,  a  month  after 
the  extraction  of  the  tooth,  there  could  be  no  doubt  of  its 
serious  nature.  Under  chloroform  I  was  able  to  pass  my 
finger  through  the  fungus  completely  into  the  antrum,  which 
was  widely  affected.  Turning  up  the  lip  without  incising 
it,  I  was  able  with  saw  and  bone-forceps  to  remove  the  floor 
of  the  antrum,  which  shows  very  well  the  disease  (College 
of  Surgeons'  Museum).  I  then  removed  the  back  of  the 
antrum,  but  the  orbital  plate  being  apparently  healthy, 
I  contented  myself  with  scraping  it  freely  and  applying  the 
chloride  of  zinc  paste,  the  age  of  the  patient  forbidding 
removal  of  the  whole  upper  jaw.  Eecurrence  took  place, 
and  I  again  scraped  away  the  growth  and  applied  the  zinc 
paste,  but  the  disease  again  made  progress,  and  the  patient 
died,  worn  out,  within  a  year  of  the  first  appearance  of  the 
disorder. 

Mr.  Butlin's  case  is  very  similar  {Pathological  Society's 
TransactioTis,  1 8  8 1 ),  and  was  that  of  a  man,  aged  sixty-two, 
who,  after  pain  in  the  jaw,  found  a  fistulous  opening  in  the 
palate,  from  which  a  foul  discharge  proceeded.  The  finger 
was  passed  easily  into  the  antrum,  and  the  cavity  was  cleared 
out,  and,  upon  recurrence  taking  place,  the  upper  jaw  was 
removed,  but  the  patient  sank  on  the  fifth  day.  Mr.  Butlin 
has  recorded  another  case  under  Mr.  M.  Baker  {Pctth.  Trans., 
1882),  in  a  woman  of  fifty-eight,  with  a  bulging  out  of  the 
right  cheek  and  an  opening  from  the  palate  into  the  antrum. 
The  upper  jaw  was  removed,  but  the  disease  was  found  to 
have  already  spread  beyond  it,  and  the  patient  died  ex- 
hausted after  a  few  days. 

The  disease  appears  so  insidiously  and  spreads  so  rapidly 
to  the  deeper  parts  that  its  prompt  recognition  is  of  the 
greatest  importance,  and  it  may,  I  think,  be  held  that  the 
attachment  of  any  growth  to  the  fangs  of  extracted  teeth 
should  excite  suspicion  as  to  the  presence  of  serious  disease 
within  the  antrum.  M.  Eeclus,  in  the  paper  referred  to, 
goes  so  far  as  to  suggest  that  the  disease  originates  in  one 
of  the  periosteal  cysts  of  the   fangs    of    the  teeth    to   be 


SARCOMA    OF    THE    ANTRUM.  169 

described,  but  it  seems  more  probable  that  it  starts  from  the 
neighbourhood  of  a  tooth,  probably  from  the  rudimentary 
paradental  epithelium,  described  by  Malassez.  The  exist- 
ence of  this  epithelium  is  fully  discussed  in  the  chapter 
on  Cysts  of  the  Jaw  (see  p.  i/o). 

In  the  cases  of  epithelioma  in  which  I  was  content  to 
operate  from  the  mouth,  the  patients  survived  for  some 
months,  whereas  in  the  two  cases  recorded  by  Mr.  Butlin, 
in  which  the  jaw  was  removed,  the  patients  rapidly  sank. 
Mr.  Ct.  Lawson  has  recorded  (Clinical  Society  s  Transac- 
tions, 1873)  a  case  of  this  disease,  in  which  he  adopted  a 
bolder,  and  apparently  more  successful,  treatment — viz.,  to 
destroy  the  skin  over  the  growth  and  the  disease  itself  with 
the  actual  cautery,  and  then  to  apply  caustic  paste  freely  so 
as  to  obtain  large  sloughs.  The  patient  was  sixty- five,  and 
made  a  good  and,  it  is  believed,  permanent  recovery.  Of 
course  there  is  the  permanent  deformity  to  be  considered, 
but,  after  all,  this  is  a  slight  drawback  if  a  cure  can  be 
obtained ;  and,  as  regards  immediate  danger  to  life,  Mr. 
Lawson  truly  remarks,  "it  must  be  borne  in  mind  that 
patients  advanced  in  life  stand  cutting  operations  very  badly, 
whilst  they  will  bear,  with  but  little  shock,  the  destruction 
of  large  growths  by  escharotics." 

Sctrcoma  of  the  Antrum. — This  variety  of  growth  may 
originate  in  the  wall  of  the  antrum  itself  or  may  spread  to  the 
antrum  from  neighbouring  parts.  The  tumours  present  the 
characters  of  sarcomata  in  other  parts  of  the  body,  and  the 
only  satisfactory  treatment  is  early  and  complete  removal. 
They  will  be  considered  fully  in  the  chapter  on  sarcoma  of 
the  upper  jaw. 


CHAPTER  XII. 

CYSTS    OF    THE    JAWS. 

In  order  to  understand  properly  the  various  theories 
advanced  to  explain  the  laode  of  origin  of  cystic  tumours  of 
the  jaws,  it  is  necessary  to  have  a  clear  idea  concerning  the 
manner  in  which  the  teeth  develop.  For  the  sake  of 
convenience  we  will  describe  what  takes  place  in  the  lower 
jaw. 

About  the  seventh  week  of  intra-uterine  life  the 
epithelium  of  the  gum  becomes  thickened  along  the  alveolar 
border  of  the  jaw,  and  the  Malpighian  layer  sends  down  a 
process  of  epithelium  into  the  subjacent  tissue.  This  down- 
growth  of  epithelium  forms  the  organ  from  which,  ultimately, 
the  enamel  is  developed  ;  and,  as  the  downgrowth  takes 
place  along  the  entire  border  of  the  jaw,  it  is  frequently 
called  the  common  enamel  germ.  A  slight  groove  on  the 
surface  of  the  gum  is  formed  by  the  epithelial  downgrowth, 
and  this  is  termed  the  primitive  dental  groove. 

As  development  proceeds,  the  changes  in  the  common 
enamel  germ  become  localised  in  certain  situations — viz., 
where  the  milk  teeth  are  eventually  developed.  At  these 
spots  the  epithelium  grows  down  in  the  form  of  flask-shaped 
bodies  termed  the  special  enamel  germs,  which  are  connected 
with  the  common  enamel  germ  by  a  narrow  band  of 
epithelial  cells,  the  neck  of  the  enamel  germ  or  funicular 
hand  (cordon  funiculaire). 

As  these  changes  in  the  epithelium  are  taking  place,  we  find 
that  the  subjacent  embryonic  connective  tissue  becomes 
differentiated  into  twenty  papillge,  each  papilla  projecting 
into,  and  forming  a  dent  in,  each  enamel  germ.     From  this 


DEVELOPMENT    OF    THE    TEETH.  171 

papilla  are  developed  the  pulp,  the  dentine,  and  the 
cementum,  and  hence  it  is  termed  the  dental  'pa'pilla. 

The  soft  embryonic  tissue  around  the  papilla  and  enamel 
germ  becomes  fibrillated  and  forms  a  kind  of  capsule.  The 
entire  structure — enamel  organ,  dental  papilla  and  fibrous 
capsule — is  termed  a  dental  follicle. 

While  the  development  of  the  milk  teeth  is  progressing, 
we  find  that  tlie  first  rudiments  of  some  of  the  permanent 
teeth  appear — viz.,  those  of  the  permanent  teeth  which 
actually  replace  the  milk  teeth.  About  the  sixteenth 
week  a  small  epithelial  downgrowth  projects  from  the 
funicular  band  above  described,  and  develops  into  the 
enamel  organ  of  the  corresponding  permanent  tooth.  From 
the  funicular  band  of  this  permanent  tooth  another  epithelial 
downgrowth  may  project,  which  in  some  animals  forms  a 
third  tooth ;  but  in  the  human  subject  it  very  rarely  forms  a 
tooth,  and  merely  represents,  in  a  rudimentary  condition, 
a  third  dentition. 

Inasmuch  as  the  permanent  molar  teeth  do  not  replace 
any  milk  teeth,  they  have  a  slightly  different  mode  of 
development.  From  the  posterior  end  of  the  common 
enamel  germ,  about  the  fifteenth  week  of  foetal  life,  a  special 
enamel  germ  develops,  and  this  eventually  forms  the  first 
molar  tooth.  Later  on,  from  the  funicular  band  of  this 
enamel  germ  the  second  molar  is  formed,  and  still  later 
from  the  funicular  band  of  this  latter  the  third  molar  or 
wisdom  tooth  is  developed. 

The  permanent  teeth  are  surrounded  by  bone,  excepting 
where  the  funicular  band  remains.  In  this  situation  there 
is  a  canal  in  the  bone  termed  the  "  iter  dentis  "  (Alberran). 
In  this  canal  there  is  a  fibrous  band  termed  the  gidjernaeulum, 
containing  columns  of  epithelial  cells  which  represent  the 
funicular  band.  As  the  permanent  tooth  is  being  cut,  it 
reaches  the  surface  by  travelling  along  the  iter  dentis. 
Any  obliteration  or  malformation  of  this  passage  might 
therefore  lead  to  an  error  in  the  development  of  the  tooth. 

In  this  account  of  the  development  of  the  teeth  it  will 
have  been  observed  that,  although  the  greater  part  of  the 


172  CYSTS    OF    THE    JAWS. 

epithelial  downgrowtli  develops  into  a  definite  structure, 
the  enamel  organ,  yet  some  part  of  it  does  not  give  rise  to 
any  permanent  or  even  temporary  organ.  For  instance, 
certain  parts  of  the  common  enamel  germ,  the  funicular 
bands,  and  epithelial  elements  from  the  enamel  organ 
representing  a  rudimentary  third  dentition,  are  destined 
to  form  no  special  structure.  The  question  naturally 
arises  :  What  becomes  of  this  epithelium  ?  It  used  to  be 
assumed  that  the  epithelial  cells  gradually  degenerated 
and  finally  disappeared.  Malassez,  however,  in  an  interesting 
series  of  papers  published  in  the  ArcMv.  de  Physiol.,  1885, 
3''serie,  showed  that  in  the  adult  jaw  these  epithelium 
cells  remain  and  form  very  definite  collections,  which  may 
be  classified  into  three  groups. 

1.  A  superficial  group  just  beneath  the  epithelium  of  the 
gum. 

2.  The  remains  of  the  neck  of  the  special  enamel  germ, 
the  funicular  band. 

3.  Groups  of  cells  originating  from  the  enamel  organ,  and 
perhaps  representing  a  rudimentary  third  dentition. 
Columns  of  epithelium  cells  belonging  to  the  last  group  are 
found,  in  adult  life,  in  the  alveolo-dental  ligament,  in  that 
part  of  the  ligament  immediately  surrounding  the  tooth. 
These  groups  of  epithelium  cells  are  termed  by  Malassez 
"  debris  epitheliaux  paradentaires." 

According  to  many  authors,  numerous  tumours  of  the 
jaws,  which  may  be  cystic,  fleshy  or  bony,  are  formed  as  the 
result  of  some  error  in  the  development  of  the  teeth.  Many 
pathologists,  and  in  this  country  especially  Bland  Sutton, 
include  these  tumours  under  the  generic  term  Odontoma, 
using  this  word  in  its  widest  sense.  Thus,  in  an  interesting 
paper  read  by  Mr.  Bland  Sutton  before  the  Odontological 
Society  of  Great  Britain,  he  stated  :  "  in  the  most  extended 
sense  an  odontoma  may  be  defined  as  a  neo^plasm  composed  of 
dental  tissues  {enamel,  dentine  and  ccmentum),  in  varying 
proportions  and  different  degrees  of  development,  arising  from 
tooth-germs,  or  teeth  still  in  the  process  of  groioth." 

Under  this   definition   of   odontoma  would   be  included, 


broca's  odontoma.  173 

dentigerous  cysts,  unilocular  cysts,  multilocular  cysts,  fibro- 
mata, hard  odoutomata,  etc. 

Inasmuch,  however,  as  the  mode  of  origin  of  many  of 
these  tumours  is  still,  more  or  less,  a  matter  of  conjecture, 
it  will  be  better  to  restrict  the  term  Odontoma  to  its  clinical 
sense,  and  include  under  it  only  the  hard  bony  tumours 
originating  in  connection  with  the  teeth. 

The  important  question  arises.  In  what  part  of  the  de- 
veloping teeth  do  these  various  tumours  originate  ?  On  this 
point  there  is  considerable  divergence  of  opinion.  Thus  Broca 
{TraiU  des  Tumcurs)  considers  that  they  originate  at  some 
stage  in  the  development  of  a  dental  follicle,  which  he  divides 
into  four  periods. 

1st  stage.  F&riode  Eiiibryoplastique. —  At  this  stage  no 
special  tooth-elements  have  developed.  There  is  simply  a 
dental  follicle,  without  any  formation  of  enamel,  dentine,  or 
cementum.  Errors  of  development  at  this  period,  according 
to  Broca,  may  give  rise  to  fibromata  (fibrous  odoutomata) 
or  to  icnilocular  cysts. 

2nd  stage.  Periodc  Odonto'plastiquc. — Here  we  find 
developed  the  special  elements  which  give  rise  to  the 
different  parts  of  a  tooth,  viz.,  enamel  cells,  dentine  cells, 
etc.  In  this  stage,  Broca  considers  that  there  may  develop 
dentigerous  cysts,  multilocular  cysts,  and  various  hard 
odoutomata. 

"^rd  stage.  Periods  Goronaire. — During  this  stage  the  actual 
formation  of  cement  and  dentine  commences,  followed  by 
a  cap  of  enamel,  and  in  this  way  the  crown  of  a  tooth  is 
formed.  Any  error  of  development  during  this  stage  Broca 
considers  may  give  rise  to  the  coronary  odoutomata. 

4.th  stage.  Pdriode  Radicidaire.  —  In  this  stage  the 
formation  of  the  fang  and  the  eruption  of  the  tooth 
take  place.  Here  we  may  get  the  development  of  radicular 
odoutomata. 

In  all  probability  Broca  is  quite  correct  in  ascribing  the 
origin  of  the  hard  odoutomata  to  errors  in  development  of 
the  dental  follicle  itself,  but  Broca's  theory  does  not  satis- 
factorily account  for  the  formation  of  the  cystic  tumours  of 


174  CYSTS    OF   THE    JAWS. 

the  jaw.  Malassez,  on  the  strength  of  his  discovery  of 
rudimentary  epithelium  in  the  adult  jaw,  considers  that  the 
cystic  tumours,  and  perhaps  certain  epitheliomata,  originate 
from  the  dSris  6pithdiaux  paradentaires.  There  are  many 
points,  as  we  shall  see  later  on,  in  favour  of  Malassez's  views, 
and  for  a  full  discussion  of  them  the  reader  is  referred  to 
the  papers  by  Malassez  in  the  ArcJiiv.  de  Physiol.  (1885, 
3°  serie),  and  to  the  papers  of  his  pupil  Alberran  in  the 
Bevue  de  Ghirurgie  (1888). 

In  this  chapter  we  will  confine  our  attention  to  the  cystic 
tumours  of  the  jaws,  which,  although  differing  in  many 
respects  from  one  another,  have  one  feature  in  common,  that 
is,  their  origination  in  all  probability,  directly  or  indirectly,  in 
connection  with  the  development  of  the  teeth.  It  is  proposed 
to  group  these  cysts  of  the  jaws  into  the  following  classes  : 

1.  Cysts  originating  in  connection  with  fully  developed 
teeth.  These  have  been  termed  "  periosteal  cysts "  by 
Magitot,  "  alveolo-dental  cysts  "  by  Forget.  It  is  convenient 
to  apply  to  them  the  term  Dented  Cysts. 

2.  Cysts  originating  in  connection  with  imperfectly  deve- 
loped teeth.  These  are  generally  termed  Dentigerous  Cysts. 
They  are  identical  with  the  "  follicular  cysts"  of  Broca. 

3.  Multilocidar  Cysts. — There  is  considerable  divergence 
of  opinion  concerning  the  origin  of  these  cysts,  and  this  point 
will  be  fully  discussed  later  on.  On  the  whole  it  is  most 
probable  that  they  originate  in  connection  with  embryonic 
tooth  structures. 

I.  Dental  Cysts. — These  cysts  contain  neither  a  tooth  nor 
the  rudiment  of  a  tooth,  and  are  divided  by  many  writers 
into  two  groups,  one  where  the  cyst  is  situated  beneath  the 
periosteum  of  the  fang  of  a  tooth — "  the  periosteal  cyst"  of 
Magitot — the  other  where  there  is  apparently  no  direct 
connection  between  the  cyst  and  a  tooth.  The  majority  of 
cases  fall  into  the  first  group.  They  are  met  with  more 
frequently  in  the  upper  than  in  the  lower  jaw,  and  generally 
in  connection  with  the  incisor  or  canine  teeth.  They  are 
usually  small  in  size,  and  may  come  away  with  the  tooth 
when  it  is    extracted.     I  am  indebted  to    Mr.    Holborow 


DENTAL    CYSTS. 


175 


King  for  three  interesting  specimens,  which  are  now  in  the 
Museum  of  the  Eoyal  College  of  Surgeons. 

Two  of  them  (Figs.  6^,  64)  are  quite  small  (one  being 
remarkable  for  the  length  of  its  pedicle)  ;  the  third  (Fig.  62) 
is  of  the  size  of  a  hazel-nut,  and  was  torn  in  extraction. 
The  contents  of  the  cysts  were  found,  on  microscopic  ex- 
amination, to  consist  of  degenerating  pus ;  their  walls  were 
formed  of  fibrous  and  granulation  tissues,  and  they  had  no 
epithelial  lining. 

The  absence  of  an  epithelial  liniug,  however,  throws  con- 
siderable doubt  upon  their  nature.  Malassez,  Alberran, 
and  others  have  shown  that  these  cysts  do  possess  an 
epithelial  lining  which,  according  to  the  latter  observer,  is 


Fig.  62. 


Fig.  63.  Fig.  64. 


composed  of  cells  similar  to  those  of  the  enamel  organ.  The 
contents  of  the  cyst  may  vary.  Usually  it  is  a  clear  fluid, 
frequently  containing  cholesterine  crystals  ;  it  may,  however, 
be  brownish  or  purulent. 

In  some  cases  the  cyst  may  reach  a  large  size,  and  in 
these  Alberran  has  shown  that  the  epithelial  lining  is 
similar  to  that  of  the  small  cysts. 

Large  cysts  which  produce  more  or  less  absorption  of  the 
outer  wall  of  the  maxilla,  are,  in  my  experience,  very  common 
consequences  of  the  retention  of  diseased  teeth,  but  seem  to 
give  surprisingly  little  inconvenience  to  the  patients,  even 
when  of  large  size  and  producing  considerable  deformity  of 
the  face.  They  are  commonly  confounded  with  cystic  dis- 
tension of  the  antrum. 

Dupuytren  remarks  that  "  morbid  changes  in  the  roots  of 


176  CYSTS    OF   THE    JAWS. 

the  teeth  give  rise  to  the  formation  of  serous  cysts,  which 
are  most  frequently  met  with  in  the  alveoli  of  the  upper 
canines,  and  in  some  instances  acquire  a  very  large  size, 
even  equal  to  that  of  the  antrum.  In  such  cases  the  root 
of  the  tooth  is  found  diseased  and  enclosed  within  the  cyst, 
which  adheres  to  the  alveolar  cavity,  and  (when  small 
enough)  usually  accompanies  the  tooth  in  its  extraction, 
but  if  left  behind,  a  suppurative  process  is  established,  which 
continues  for  a  long  time.  The  fluid  yielded  by  these  cysts 
is  sometimes  very  thick,  and  in  other  instances  of  a  serous 
character,  and  their  inner  surface  is  as  smooth  as  that  of  the 
serous  membranes.'"  ("  On  Diseases  of  Bone,"  Sydenham 
Society's  translation,  p.  440.) 

Of  this  kind  probably  also  was  the  case  mentioned  by 
Sir  J.  Paget  ("  Surgical  Pathology,"  p.  402),  of  a  woman, 
aged  thirty-eight,  who  had  a  tumour  simulating  a  collection 
of  fluid  in  the  antrum,  but  which  projected  beneath  the 
mucous  membrane  of  the  upper  jaw  above  the  teeth,  and  had 
existed  six  years.  An  incision  evacuated  an  ounce  of  turbid 
brownish  fluid,  sparkling  with  crystals  of  cholesterine,  and 
it  then  appeared  that  there  was  no  connection  with  the 
antrum,  but  that  it  rested  in  a  deep  excavation  in  the  alveolar 
border  of  the  jaw.  So  also  the  case  mentioned  by  the  same 
author  in  connection  with  the  incisor  teeth. 

Delpech  relates  a  case  in  which  a  membranous  cyst  con- 
tained three  ounces  of  fluid,  but  its  interior  bore  no  re- 
semblance to  the  interior  of  the  antrum ;  and  Stanley 
(p.  300)  narrates  a  case  of  Sir  W.  Lawrence's  of  large  cyst 
projecting  in  the  situation  of  the  antrum,  and  containing  a 
glairy  fluid  with  shining  particles  in  it,  and  regards  both 
cases  as  instances  of  cysts  connected  with  the  teeth,  although 
it  appears  more  probable  that  they  were  examples  of  cyst  in 
the  antrum,  such  as  have  been  already  described. 

A  case,  which  I  have  little  doubt  originated  in  a  cyst  in 
connection  with  the  incisor  teeth,  but  in  which  the  antrum 
had  become  secondarily  involved,  has  lately  been  under  my 
own  care.  The  patient,  a  woman  aged  forty,  had  a  fluc- 
tuating swelling,  noticed  for  two  years,  immediately  above 


DENTAL    CYSTS.  177 

the  incisor  teeth,  which  were  decayed  even  with  the  gum. 
On  incising  it,  a  quantity  of  yellowish  glairy  fluid  exuded, 
and  a  probe,  when  introduced,  evidently  passed  into  the 
antrum.  From  the  position  of  the  cyst,  and  its  close  proximity 
to  the  incisor  teeth,  I  have  no  doubt  it  originated  from  them, 
and  found  its  way  into  the  antrum  by  absorption  of  the  bony 
wall.  The  patient  would  not  consent  to  any  operation  for  the 
cure  of  the  disease,  which  gave  her  little  inconvenience. 

Fischer,  of  Ulm  (Gurlt's  Jalireshericlit,  1859,  p.  154), 
has  narrated  three  cases  of  cyst  connected  with  the  fangs  of 
teeth,  in  one  of  which  he  had  the  opportunity  of  making  a 
post-mortem  examination.  After  the  removal  of  the  facial 
wall  of  the  antrum,  there  appeared  a  cyst  connected  with 
the  apex  of  the  posterior  molar  tooth,  which  filled  the  whole 
antrum  without,  however,  adhering  to  the  mucous  mem- 
brane. This  consisted  of  a  perfectly  closed  serous  bag  of 
^"'  thickness,  with  a  smooth  inner  surface,  and  containing 
a  yellowish  serous  fluid,  which  grew  from  the  periosteum  of 
the  apex  of  the  root  of  the  tooth. 

Although  more  common  in  the  upper  jaw,  dental  cysts  are 
found  in  the  lower  jaw.  They  usually  occur  in  direct  con- 
nection with  the  teeth,  but  sometimes  they  have  apparently 
no  immediate  relation  with  them.  In  these  cases  it  is 
very  probable  that  some  irritation  connected  with  these 
organs  may  have  been  the  original  cause  of  the  mischief. 
Of  this  a  most  remarkable  specimen  from  a  woman,  aged 
forty-five,  is  to  be  seen  in  St.  George's  Hospital  Museum. 

The  cyst  is  for  the  most  part  single,  and  contains  merely 
fluid,  which  may  be  clear  or  more  or  less  coloured.  Du- 
puytren  narrates  several  cases  of  the  kind  ( "  Diseases  of 
Bone,"  Sydenham  Society's  translation,  p.  437),  from  some  of 
which  only  reddish-coloured  serum  escaped  on  their  being 
opened,  whilst  in  others  a  fibroid  growth,  and  in  one  osseous 
nodules  were  found  within  them.  There  is  a  good  example 
of  a  single  cyst,  for  which  a  piece  of  the  entire  thickness  of 
the  lower  jaw  was  excised,  in  St.  George's  Museum,  of  which 
the  following  are  the  particulars  :  The  patient  had  had  a 
tumour,  supposed  to  be  an  epulis,  removed  from  the   same 

M 


17§ 


CYSTS    OF   THE   JAWS. 


spot  two  years  before,  and  the  disease  had  been  gro wing- 
since  that  time.  When  admitted  the  tumour  was  found  to 
be  a  firm  oval  growth,  about  the  size  of  an  orange,  connected 
with  the  outer  surface  of  the  right  inferior  maxilla.  It  was 
evidently  cystic,  and  there  was  an  indistinct  sensation  of 
fluctuation.  The  tumour,  as  well  as  the  portion  of  bone 
from  which  it  grew,  was  removed  by  an  incision  in  the 
median  line.  The  extent  of  lower  jaw  removed  was  from  the 
lateral  incisor  tooth  on  the  left  side  to  the  angle  of  the  jaw 
on  the  right. 

The  accompanying  drawings  show  a  case  of  unilocular  cyst 

Fig.  65. 


of  the  lower  jaw,  for  which  Sir  William  Fergusson  removed 
a  large  portion  of  the  bone.  Fig.  65  shows  the  growth,  and 
Figs.  66  and  6^  the  patient  before  and  after  the  operation 
(see  "  Practical  Surgery,"  p.  666). 

Etiology  and  Pathology. — Numerous  theories  have  been 
advanced  to  explain  the  origin  of  these  cysts.  Tomes  and 
Magitot  consider  that  their  starting-point  is  an  inflammation 
of  the  alveolo-dental  periosteum,  which,  instead  of  forming  an 
abscess,  leads  to  the  development  of  a  serous  cyst.  There 
are  difficulties  in  the  way  of  accepting  this  theory,  especially 
as  regards  the  epithelial  lining.  It  is  difficult  to  explain, 
on  the  inflammatory  theory,  the  formation  of  a  distinct 
epithelium.  Verneuil,  Eeclus,  and  especially  Malassez,  con- 
sider that  a  more  feasible  explanation  of  the  occurrence  of 


CYST    OF   THE    LOWER  JAW. 
Fig.  66. 


179 


Fig.  67. 


180  CYSTS    OF    THE    JAWS. 

cysts  is  to  be  found  in  their  origin  from  rudiments  of  the 
enamel  organ,  or,  as  Malassez  terms  it,  "  debris  epitheliaux 
paradentaires."  This  epithelium  may  begin  to  hypertrophy 
as  a  result  of  the  irritation  set  up  by  micro-organisms 
spreading  from  a  carious  focus  in  a  tooth,  or  as  the  result  of 
an  operation  on  a  tooth. 

It  is  difficult,  on  the  inflammatory  theory,  to  explain  the 
mode  of  origin  of  those  dental  cysts  which  originate  at  some 
distance  from  the  alveolo-dental  periosteum.  On  the  theory 
of  Malassez,  however,  there  is  no  difficulty  in  explaining  that 
some  elements  of  the  primitive  enamel  germ  have  remained, 
but  not  in  immediate  contact  with  the  tooth.  In  favour  of 
this  theory  also  is  the  fact  that,  after  treatment  of  these 
cysts  and  apparent  cure,  a  recurrence  has  taken  place. 
This  recurrence  may  be  only  a  unilocular  cyst,  but  a  multi- 
locular  cyst,  and  even  a  more  or  less  solid  epitheliomatous 
growth,  has  been  described. 

Symptoms. — The  patient  finds  that  he  has  a  slowly  grow- 
ing tumour  of  the  jaw,  which  at  first  is  painless,  and  gives 
him  no  trouble  except  from  the  deformity.  The  outer  plate 
yields  ordinarily  to  the  pressure  of  the  growing  cyst,  and 
thus  a  prominent  smooth  tumour  is  formed,  over  which  the 
skin  is  freely  movable.  When  the  bony  wall  is  sufficiently 
attenuated,  the  peculiar  crackling  already  described  may  be 
produced  on  pressure,  and  if  the  disease  is  still  unchecked 
the  bone  becomes  entirely  absorbed,  and  nothing  but  a 
membranous  cyst,  with  particles  of  osseous  matter  em- 
bedded in  it,  remains.  Later  on,  owing  to  the  tension  of 
the  accumulating  fluid,  more  or  less  pain  may  be  present, 
radiating  into  the  molar  or  frontal  regions,  or  even  on  to  the 
scalp. 

The  diagnosis  and  treatment  of  these  cases  will  be  con- 
sidered in  connection  with  dentigerous  cysts. 

2.  Dentigerous  Cysts. — These  cysts  contain  one  or  more 
teeth  in  their  interior  or  in  their  wall.  The  teeth  may  be 
well  formed,  or  may  be  quite  rudimentary,  consisting  of 
irregular  masses  of  bone  and  enamel.  They  are  almost 
invariably    connected   with    permanent    teeth,   though    Mr. 


DENTIGEROUS    CYSTS.  181 

Salter  mentions  a  case  in  connection  with  a  temporary 
molar  occurring  in  the  practice  of  Mr.  Alexander  Edwards, 
late  of  Edinburgh  ;  and  in  a  remarkable  specimen  belonging 
to  Mr.  Oartwright,  which  will  be  afterwards  referred  to,  the 
tooth  is  a  supernumerary  one.  I  have  also  myself  met  with 
an  example  of  cyst  connected  with  a  temporary  tooth  in  a 
boy  of  four  years,  brought  to  me  by  Mr.  0.  J.  Fox.  In  this 
case  the  temporary  right  canine  tooth  was  wanting,  and 
there  was  a  cyst  developed  in  its  situation,  on  cutting  into 
which  I  extracted  seven  small  irregular  nodules  of  dentine 
and  enamel,  but  no  complete  tooth,  this  being  therefore  an 
example  of  the  odonto-plastic  cyst  of  Magitot. 

As  a  rule  the  cysts  are  single,  but  occasionally  they  consist 
of  two  compartments,  which  may  or  may  not  communicate. 
Their  contents  are  ordinarily  clear  fluid,  sometimes  bloody, 
occasionally  filamentous  or  gelatinous,  and  still  more  rarely 
they  contain  a  sebaceous  matter  like  mastic,  composed  almost 
entirely  of  epithelium. 

The  tooth  may  lie  free  in  the  cavity  of  the  cyst,  or,  which 
is  more  usual,  it  may  be  implanted  in  the  wall  of  the  cyst 
with  the  crown  projecting  into  the  cavity.  In  the  majority 
of  cases  it  presents  the  characters  of  a  molar  tooth.  Instead 
of  one  tooth,  several  may  be  found,  which  are  generally  more 
or  less  rudimentary. 

The  cyst  waU  is  composed  of  two  parts,  an  external 
fibrous  layer  and  an  internal  layer  lined  with  epithelium, 
which,  according  to  Alberran  {Bemie  de  Ghir.,  1888),  is 
similar  to  that  of  the  enamel  organ. 

Dentigerous  cysts  are  met  with  more  frequently  in  the 
lower  than  in  the  upper  jaw,  thus  differing  from  dental  cysts. 

Etiology  and  Pathology. — Owing  to  the  difficulty  in  ob- 
serving the  early  stages  in  the  growth  of  these  cysts,  it 
is  not  surprising  to  find  that  observers  are  by  no  means 
vmanimous  in  the  theories  they  advance.  According  to  Broca 
{Trait6  des  Tumeurs,  vol.  ii,  p.  35),  dentigerous  cysts  origi- 
nate by  changes  taking  place  within  the  tooth  follicle.  The 
space  between  the  follicle  and  the  dental  papilla  is  occupied 
by  the  enamel  organ,  an  organised  body,  but  very  soft  and 


182  CYSTS    OF    THE   JAWS. 

gelatinous,  apt  to  disappear  under  morbid  influences,  and 
thus  leaving  in  the  follicle  a  cavity  ready  to  be  transformed 
into  a  cyst.  If  the  cyst  begins  to  develop  at  an  early 
period,  the  dental  papilla  undergoes  atrophy  as  a  result  of 
the  pressure  of  the  accumulating  liquid,  and  no  tooth,  or 
even  rudiment  of  a  tooth,  is  formed.  If,  however,  the  dental 
papilla  have  reached  some  development  before  the  cyst  forms, 
some  rudiment  of  a  tooth  will  be  found.  Finally,  in  some 
cases  the  crown  of  the  tooth  may  have  been  completely 
formed  before  the  development  of  the  cyst. 

Mr.  Tomes  explains  the  formation  of  cysts  in  connection 
with  retained  teeth  by  referring  to  the  fact  that,  when  the 
development  of  the  enamel  of  a  tooth  is  completed,  its  outer 
surface  becomes  perfectly  detached  from  the  investing  soft 
tissue,  and  a  small  quantity  of  transparent  fluid  not  uncom- 
monly collects  in  the  interval  so  formed.  This  fluid  ordinarily 
is  discharged  when  the  tooth  is  cut,  but  when  from  some 
cause  the  eruption  of  the  tooth  is  prevented,  it  increases  in 
quantity,  gradually  distending  the  surrounding  tissues  in  the 
form  of  a  cyst. 

Malassez  explains  the  origin  of  dentigerous  cysts  in  the 
same  manner  as  he  explains  the  formation  of  dental  cysts^ 
viz.,  by  the  hypertrophy  of  epithelial  rudiments  of  the 
enamel  organ. 

Alberran,  while  supporting  the  views  of  Malassez,  lays 
considerable  stress  upon  the  part  played  by  the  "iter  cUntis" — 
i.e.,  a  bony  canal  which  leads  from  the  gum  to  the  socket  of 
a  permanent  tooth.  In  this  canal  is  a  fibrous  band,  in  which 
can  be  found  columns  of  epithelial  cells,  similar  to  those  of 
the  enamel  organ.  As  the  fang  develops  the  tooth  is  pushed 
along  the  canal  to  the  surface.  If,  however,  the  canal  should 
become  blocked,  or  its  direction  altered,  the  tooth  might  find 
considerable  difficulty  in  reaching  the  surface.  Under  these 
circumstances  the  irritation  might  lead  to  a  proliferation  of 
the  rudimentary  epithelium. 

In  the  face  of  these  conflicting  theories  it  is  impossible  at 
present  to  account  satisfactorily  for  the  origin  of  dentigerous 
cysts. 


DENTIGEROUS    CYSTS.  183 

Symptoms. — Although  dentigerous  cysts  are  more  common 
in  the  lower  than  in  the  upper  jaw,  yet  Mr.  Salter,  in  his 
work  on  "  Dental  Pathology  and  Surgery,"  has  collected 
several  cases  of  dentigerous  cyst  in  the  upper  jaw,  which 
were  recognised  and  treated  during  life.  Thus,  Jourdain 
records  three  cases,  one  in  a  girl  of  seventeen,  in  whom  the 
first  and  second  right  upper  permanent  molars  were  inverted 
and  the  surrounding  cyst  had  involved  the  antrum  ;  a  second, 
in  a  man  of  sixty,  connected  with  a  bicuspid  tooth  of  the 
upper  jaw ;  and  the  third  in  a  girl  of  thirteen,  connected 
with  an  upper  lateral  incisor.  Dupuytren  and  Bransby 
Cooper  each  met  with  a  case  in  the  upper  jaw,  Dupuy- 
tren's  case,  which  was  shown  to  him  by  M.  Loir,  being  a 
remarkable  instance  of  a  cyst  developed  between  the  plates 
of  the  palatine  process  of  the  upper  jaw  {sec  Dupuytren 
"  On  Diseases  of  Bone,"  Sydenham  Society's  translation, 
p.  438). 

Professor  Baum  also  met  with  an  extraordinary  case  in 
a  woman,  aged  thirty-eight,  both  of  whose  antra  were  enor- 
mously dilated  by  cysts,  from  one  of  which  a  canine  tooth, 
^-ind  from  the  other  a  molar  tooth,  was  removed.  Mr.  Salter 
gives  two  cases  of  his  own,  which  will  be  found  at  length 
in  the  Cruy's  Hospital  Reports,  1859;  ^^^  depending  upon 
the  impaction  of  a  wisdom-tooth  in  the  lower  jaw  of  a  man, 
aged  twenty-two,  and  the  other  in  a  girl  of  eighteen,  who 
had  an  elastic  fluid-containing  tumour  in  the  incisive  region 
of  the  upper  jaw,  connected  with  a  permanent  incisor  tooth, 
the  fang  of  which  was  not  developed,  and  whose  place  was 
occupied  by  a  temporary  tooth. 

Inversion  of  the  tooth  appears  to  be  a  frequent  accom- 
paniment, or  rather  the  cause,  of  these  cysts,  and  occurred 
in  one  of  the  cases  narrated  by  Jourdain,  and  in  those  of 
Dupuytren  and  Bransby  Cooper.  Mr.  Tomes  ("Dental 
Surgery  ")  has  recorded  a  similar  case  in  a  girl  of  sixteen, 
who  had  a  swelling  around  the  second  molar  tooth  of  the 
lower  jaw,  which  proved  to  be  a  cyst.  After  being  tapped 
the  cyst  suppurated,  and  the  extraction  of  the  tooth  became 
necessary,  when  the  inverted  crown  of  the  third  molar  was 


184 


CYSTS   OF    THE    JAWS. 


found  lodged  between  the  expanded  fangs  of  the  second 
molar  tooth,  the  two  being  united  by  dentine,  and  haxdng 
one  common  pulp-cavity,  as  seen  in  the  accompanying  draw- 
ing, Fig.  6S,  from  Mr.  Tomes'  work. 

Cases  of  dentigerous  cysts  may  be  mistaken  for  solid 
tumours.  Thus  Gensoul,  of  Lyons,  has  recorded  the  case  of 
a  girl  of  thirteen,  whose  antrum  was  distended  with  a  large 
collection  of  yellow  fluid,  and  contained  a  canine  tooth  at- 
tached to  its  wall,  in  whom  he  had  made  the  incisions 
necessary  for  the  removal  of  the  tumour  before  he  discovered 
its  nature.  Mr.  Syme  also  has  related  (Edinhurgh  Medical 
and  Surgical  Joiirnal,i8^S)  the  case  of  a  woman,  aged  thirty- 
one,  on  whom  he  operated  for  a  tumour  of  the  upper  jaw  of 

Fig.  68. 


four  months'  standing,  by  laying  open  the  cheek  and  re- 
moving the  tumour  with  the  bone-forceps.  "  The  tumour 
was  found  to  consist  of  a  dense  cyst,  lined  throughout  with 
earthy  matter  in  a  crystalline  form,  and  containing  a  clear 
glairy  fluid,  together  with  the  crown  of  a  tooth,  apparently 
the  lateral  incisor."  In  a  cavity  beyond  the  tumour  was 
found  a  fully  formed  canine  tooth,  encrusted  with  a  thin 
plate  of  bone.  The  teeth  are  said  to  have  belonged  to  the 
temporary  set. 

Wlien  dentigerous  cysts  occur  in  the  lower  jaw  they  form 
more  isolated  and  prominent  tumours  than  in  the  case  of 
the  upper  jaw,  and  in  some  cases  the  projecting  bony  wall 
has  been  removed.  In  St.  Bartholomew's  Museum  is  a 
specimen  of  the  kind,  consisting  of  a  portion  of  a  bony  cyst, 
which  was  removed  by  Mr.  Earle  from  the  external  and 
lateral  part  of  a  lower  jaw.  The  cyst  is  lined  with  a  thick 
and  soft  membrane,  which  has  been  in  part  separated  from 
it.     The  cavity  of   the  cyst  was   filled  with  a  glairy  fluid. 


DENTIGEROUS    CYSTS. 


185 


and  at  the  bottom  of  it  a  canine  tooth  of  the  second  set  was 
adherent  to  the  lining  membrane.  The  case  is  referred  to 
by  Stanley,  who  gives  an  accurate  drawing  of  the  prepara- 
tion. In  the  Museum  of  the  College  of  Surgeons  there  is  a 
very  similar  preparation,  showing  a  bony  cyst  of  oval  shape, 
one  inch  in  its  long  diameter,  lined  with  a  thick  well-formed 
membrane,  containing  an  imperfectly  formed  bicuspid  tooth, 
which  was  removed  by  Mr.  Wormald  from  the  lower  jaw  of 
Fig.  69.  Fig.  70. 


a  female,  aged  seventeen,  whose  case  will   be  found  in  the 
Lancet,  June  22nd,  1850. 

When  the  cyst  occurs  in  the  lower  jaw,  and  is  less  pro- 
minent than  in  the  two  cases  already  mentioned,  giving  rise 
to  a  general  expansion  of  the  bone  rather  than  a  distinct 
tumour,  the  disease  may  be  mistaken  for  a  solid  tumour  of 
the  lower  jaw.  A  case  of  this  kind  occurred  to  that  excel- 
lent surgeon,  the  late  Mr,  S.  W.  Eearn,  of  Derby,  who  had 
the  courage  and  honesty  to  publish  the  case  {British  Medical 
Journal,  August  27th,  1864),  and  to  whom  I  was  indebted 
for  the  very  valuable  preparation  now  in  the  College  of 
Surgeons'  Museum,  from  which  the  drawings,  Tigs.  69  and 
70,  were  made. 


186  CYSTS    OF   THE   JAWSl 

Mr.  Fearn's  patient  was  a  girl  of  thirteen,  wlio  had  a 
large  resistant  tumour  of  the  left  side  of  the  lower  jaw, 
which  had  been  growing  six  months.  There  was  some 
enlargement  also  of  the  right  side,  and  the  teeth  there  were 
very  irregular.  The  teeth  on  the  left  side  had  been  ex- 
tracted, with  the  exception  of  the  second  molar  and  a 
temporary  molar.  No  opening  could  be  detected  in  the 
tumour,  though  there  was  a  constant  offensive  discharge 
from  its  surface.  Mr.  Fearn  removed  the  left  half  of  the 
jaw  from  the  symphysis  to  the  articulation,  and  on  division 
of  the  bone  with  the  saw  a  quantity  of  foetid  pus  escaped. 
The  tumour  (Fig.  69)  proved  to  be  a  bony  cyst  formed  by 
the  expansion  of  the  two  plates  of  the  jaw,  which  extended 
for  some  distance  to  the  right  of  the  symphysis  (a  very 
unusual  occurrence).  The  cavity  is  lined  with  a  thick 
vascular  membrane,  and  at  the  bottom  the  canine  tooth 
will  be  seen  projecting  from  the  wall.  The  case  was  evi- 
dently therefore  one  of  dentigerous  cyst,  due  to  the 
non-development  of  the  canine  tooth,  the  contents  of  which 
had,  from  some  cause,  become  purulent.  The  mental 
foramen,  with  the  nerve  emerging,  is  still  visible  in  the 
preparation  and  drawing  (Fig.  70).  The  patient  made  a 
good  recovery. 

A  very  similar  case  is  recorded  by  Dr.  Forget,  in  his 
essay  on  Les  Anomalies  Dentaires  et  leur  influence  sur  la 
'production  cles  Maladies  des  Os  Maxillaires,  1859,  which 
is  translated  by  Mr.  R.  T.  Hulme,  in  the  Dental  Review, 
i860.  The  patient  was  a  woman,  aged  thirty,  who  had  a 
tumour  on  the  right  side  of  the  lower  jaw,  of  the  size  of  a 
hen's  egg,  extending  from  the  lateral  incisor  to  the  base  of 
the  coronoid  process,  which  had  been  growing  ten  years, 
M.  Lisfranc  removed  half  the  jaw,  and  the  patient  made  a 
good  recovery.  An  examination  of  the  tumour  showed  it  to 
be  a  cyst,  at  the  bottom  of  which  lay  the  wisdom  tooth,  the 
crown  projecting  downwards  into  it,  the  fang  being  inverted 
and  fixed  in  the  base  of  the  coronoid  process.  In  the 
illustration  (Fig.  71),  (for  which  I  am  indebted  to  Mr. 
Hulme),  the  cyst  has  been  opened,  the  internal  wall  h  being 


DENTIGEROUS    CYSTS. 


187 


left ;  a  marks  the  position  of  the  tooth,  and  c  the  inferior 
dental  canal,  which  has  been  opened  to  show  its  non- 
communication with  the  cyst. 

M.  Legouest  brought  under  the  notice  of  the  Soci^te  de 
Chirurgie  de  Paris,  in  1862,  a  very  similar  case,  which  had 
the  peculiarity  of  pulsating  at  one  point  synchronously  with 
the  radial  pulse.  The  supposed  tumour  proved  to  be  a 
dentigerous  cyst  containing  two  teeth,  the  pulsation  having 
been  due  to  the  great  vascularity  of   the  membrane  cover- 

FiG.  71. 


ing  it,  and  the  great  pain  which  had  been  experienced,  to 
the  fact  that  the  dental  canal  was  opened,  and  the  nerve 
pressed  upon  by  the  cyst  (Gazette  des  Hopitaux,  August  7th, 
1862). 

In  the  Annali  Universali  cli  Medicina  for  May  1867, 
Sig.  Bottini,  of  Novara,  has  recorded  a  case  of  "  sub-periosteal 
and  sub-capsular  disarticulation  "  of  the  left  half  of  the  lower 
jaw  of  a  woman,  aged  twenty-three,  for  what  proved  to  be 
a  dentigerous  cyst  in  connection  with  the  wisdom  tooth. 

Mr.  Underwood  has  allowed  me  to  have  the  accompanying 
drawing  (Fig.   72)  taken  from  the  model  of  a  preparation 


188  CYSTS    OF    THE   JAWS. 

which  he  possesses,  showing  very  heautifully  a  cyst  of  the 
lower  jaw,  which  was  removed  by  M.  Maisonneuve  by 
sawing  through  the  bone  at  two  points.  The  canine  tooth 
is  seen  lying  horizontally  at  the  bottom  of  the  cyst.  The 
patient,  aged  fifty-six,  had  a  swelling  in  the  lower  jaw  near 
the  chin,  and  an  opening  formed  behind  one  of  his  front 
teeth,  from  which  a  saline  fluid  escaped.  The  man  made  a 
good  recovery  from  the  operation.  (Vide  British  Journal 
of  Dental  Science,  1862,  p.  562.) 

Dentigerous  cysts,  like  other  cysts,  may  undergo  altera- 

FiG.  72.  Fig.  73. 


tion,  not  only  of  the  contents,  but  of  the  cyst-wall.  The 
opportunities  for  recognising  such  changes  are  exceedingly 
rare,  and  the  only  known  specimen  of  the  kind  is  one 
presented  by  Mr.  Samuel  Cartwright  to  the  Eoyal  College  of 
Surgeons'  Museum,  which  shows  calcification  of  the  cyst- wall. 
The  preparation  (Fig.  73)  is  one  of  the  right  superior  maxilla, 
which,  having  been  opened,  shows  a  bony  cyst  within  the 
antrum  and  attached  to  its  floor,  but  unconnected  with  it 
elsewhere.  The  cyst  has  been  opened,  and  contains  a  super- 
numerary tooth  loose  in  its  cavity,  though  no  doubt  originally 
attached  to  its  base.  This  is  clearly  a  case  of  dentigerous  cyst 
which  has  undergone  calcification,  and  which,  had  it  been 
expanded  to  a  greater  degree  before  this  change  took    lace. 


DENTIGEKOUS    CYSTS. 


189 


would  in  all  probability  have  been  inseparably  united  with 
the  walls  of  the  antrum. 

In  some  cases  the  contents  of  a  dentigerous  cyst  may 
completely  disappear,  as  in  the  following  case  : 

The  accompanying  engraving  (Fig.  74)  shows  a  cyst  of 
the  lower  jaw  occurring  in  a  man,  aged  thirty-four,  who  was 
under  my  care  in    1878.     The  swelling  began  nine  years 

Fig.  74. 


before,  and  was  of  the  size  of  an  ordinary  orange,  round, 
very  hard,  and  fixed  to  the  angle  of  the  lower  jaw  on  the 
right  vside.  Its  edges  were  well  defined,  there  was  no  fluc- 
tuation nor  pulsation,  except  that  of  the  facial  artery,  which 
was  stretched  over  the  tumour.  Externally  the  tumour  ap- 
peared to  be  solid,  but  examined  from  the  mouth,  the 
anterior  part  of  the  wall  yielded  slightly  to  firm  pressure. 
On  puncturing  from  the  mouth  through  the  bony  wall  I 
entered  a  large  empty  cavity  lined  with  soft  tissue,  which  on 
microscopical  examination  showed  portions  of  hyaline  cartilage 
and  cartilage  with  a  faintly  fibrous  matrix,  surrounded  by, 


190  CYSTS    OF    THE    JAWS. 

and  gradually  passing  into,  oval  and  spindle  cells.  The  bony- 
walls  of  the  cyst  were  broken  down  and  partially  cut  away, 
and  this  proceeding  was  repeated  a  fortnight  later.  The 
tumour  gradually  diminished  as  suppuration  went  on,  several 
pieces  of  bone  being  removed,  and,  six  weeks  after  the  cyst 
had  been  opened,  a  tooth  was  felt  fixed  at  the  bottom  of  the 
cavity,  and  on  being  extracted  proved  to  be  a  bicuspid  with 
a  perfect  crown  and  two  small  fangs.  After  this  the  cavity 
closed  and  the  swelling  entirely  disappeared.  The  case  is 
remarkable,  both  for  the  age  of  the  patient  and  also  for  the 
fact  that  the  cyst  was  empty,  the  fluid  which  must  have 
been  present  at  one  time  having  become  absorbed.  A  careful 
search  for  a  tooth  was  made  at  the  time  of  the  operation, 
but  one  could  not  be  found,  and  its  discovery  at  a  later  date 
was  probably  due  to  the  destruction  by  suppuration  of  the 
lining  membrane  of  the  cyst,  which  had  completely  en- 
veloped it. 

In  the  Museum  of  the  Eoyal  College  of  Surgeons  is  a 
preparation  of  the  right  side  of  the  body  of  the  lower 
jaw,  completely  and  uniformly  dilated  into  a  large  sphe- 
rical cyst.  N"o  tooth  or  rudiment  of  a  tooth  can  be 
discovered  in  the  cyst,  but  its  inner  surface  is  lined  by  a 
layer  of  small  epithelial  cells  and  is  thrown,  in  places,  into 
thick  projecting  folds.  Mr.  Eve  considers  it  probable  that 
the  cyst  originated  in  the  enamel-organ  of  an  abortive  wis- 
dom or  supernumerary  tooth,  and  hence  would  consider  it  an 
example  of  the  follicular  cyst  developed  in  the  embryonic 
period  (Magitot). 

Diagnosis  of  Dental  and  Dentigerous  Cysts. — A  careful 
examination  of  the  mouth  may  reveal  the  absence  of  a  per- 
manent tooth,  or,  as  in  one  of  Mr.  Salter's  cases,  may  show 
a  temporary  tooth  occupying  a  permanent  position,  and  this 
would  direct  the  mind  of  the  surgeon  to  the  possible  exist- 
ence of  a  dentigerous  cyst.  On  the  other  hand,  however,  it 
must  be  remembered  that  teeth  may  be  wanting  without 
being  connected  with  any  disease  ;  thus,  I  am  acquainted 
with  a  family  who  have  the  hereditary  peculiarity  of  a  single 
bicuspid  tooth  on  each  side. 


DENTAL    AND    DENTIGEROUS    CYSTS.  191 

If,  however,  the  permanent  teeth  have  been  erupted  nor- 
mally, and  one  or  more  of  them  in  the  region  of  the  cyst  be 
decayed,  then  the  probability  is  that  we  are  dealing  with  a 
dental  cyst  and  not  a  dentigerous  cyst.  We  should  also 
bear  in  mind  that  dental  cy^ts  are  usually  in  the  upper  jaw 
and  connected  with  canine  or  incisor  teeth,  whereas  denti- 
gerous cysts  are  more  often  in  the  lower  jaw,  and  connected 
with  the  molar  teeth. 

When  a  cyst  is  sufficiently  expanded  for  the  wall  to  yield 
under  the  finger  with  the  characteristic  parchment-like 
crackle,  there  can  be  no  difficulty  in  its  recognition,  but 
without  this  it  is  impossible  in  all  cases  to  distinguish 
between  a  cyst  and  a  slow-growing  solid  tumour.  Under 
these  circumstances,  it  is  well  to  insist  upon  the  propriety 
of  making  an  exploratory  puncture  in  all  cases  which  are 
not  obviously  solid  growths,  and  have  sprouted  so  that  their 
nature  can  be  certainly  recognised.  The  puncture  being 
made  within  the  mouth  will  be  of  no  moment  should  a  more 
severe  operation  subsequently  be  necessary. 

Treatment  of  Dental  and  Dentigerous  Cysts. — Of  recent 
years  it  has  been  noticed  that  occasionally,  after  incision  and 
drainage  of  these  cysts,  a  recurrence  has  taken  place.  This 
recurrence  usually  takes  the  form  of  a  unilocular  or  multi- 
locular  cyst,  but  occasionally  an  epitheliomatous  growth  is 
found.  If  we  accept  Malassez's  views  concerning  the  mode 
of  origin  of  these  cysts — viz.,  in  rudimentary  epithelial  struc- 
tures— it  is  not  difficult  to  understand  how  the  recurrence 
may  take  place. 

It  is  therefore  a  most  important  point  in  the  treatment  to 
see  that  the  whole  of  the  cyst  wall  is  removed  or  destroyed. 
At  the  same  time  any  teeth  or  rudiments  of  teeth  in  con- 
nection with  the  cyst  must  be  got  rid  of.  It  will  usually 
be  necessary  to  excise  a  portion  of  the  front  wall  of  the  cyst 
so  that  the  rest  of  the  cyst  wall  can  be  removed.  If  this  be 
impossible,  the  cavity  should  be  swabbed  out  with  a  strong 
caustic,  such  as  a  solution  of  chloride  of  zinc,  gr.  xl.  to 
the  oz.,  or  the  cyst  wall  may  be  cauterized.  This  may  be 
accomplished  in  most  instances  without  any  incision  of  the 


192  CYSTS    OF    THE    JAWS. 

integuments,  and  in  the  few  more  extensive  cases  by  simply- 
dividing  the  lip,  and  carrying  the  incision  into  the  nostril. 

In  cases  where  a  permanent  opening  into  the  antrum  is 
not  required,  it  will  be  sufficient  to  turn  up  a  sort  of  trap- 
door, as  suggested  by  0.  Weber,  the  periosteum  serving  as 
the  hinge,  so  that  it  may  be  replaced  after  the  removal  of 
the  contained  cysts.  It  can  but  rarely  happen  that  such  an 
extensive  mutilation  can  be  requisite  as  is  shown  in  a  pre- 
paration in  Guy's  Hospital  Museum,  consisting  of  the 
outer  wall  of  the  antrum  and  the  palatine  plate,  contain- 
ing all  the  teeth  of  the  left  side  except  the  central  incisor, 
which  was  removed  by  Mr.  Key  from  a  case  of  very  greatly 
distended  antrum. 

In  the  case  of  dentigerous  cysts  of  the  lower  jaw  it  will, 
after  removal  of  a  portion  of  the  wall,  be  advisable  to 
squeeze  the  plates  together  as  far  as  possible,  and,  in  the 
case  of  the  upper  jaw,  pressure  by  pads  and  bandages,  as  re- 
commended by  Listen,  will  do  much  to  restore  the  parts  to 
their  usual  form.  Dr.  Forget  relates  the  case  of  a  woman,  of 
about  thirty,  with  a  hemispherical  tumour  of  the  right  side 
of  the  lower  jaw,  which  was  produced  by  the  bulging  of  the 
external  plate  of  the  ramus  of  the  jaw,  the  internal  having 
preserved  its  usual  position.  M.  Nelaton  exposed  the 
tumour,  and  making  a  hole  in  the  outer  wall  found  a  tooth 
projecting  into  the  cyst.  The  tooth  was  extracted  with 
some  difficulty,  and  the  patient  perfectly  recovered,  and  was 
well  ten  years  after.  The  accompanying  illustration  (Fig.  75) 
represents  the  relation  of  the  parts,  l  pointing  out  the  posi- 
tion of  the  tooth  {Dental  Bevieio,  i860). 

The  cyst  should  always  be  reached  by  dividing  the  mucous 
membrane  within  the  mouth,  and  without  incising  the  cheek  ; 
but,  if  necessary,  a  single  line  of  incision  only  should  be  made, 
so  that  as  little  after-deformity  as  possible  may  be  produced. 

3.  Multilocular  Cysts. — Since  the  first  case  of  multi- 
locular  cyst  of  the  jaw  described  by  Mr.  Cusack  in  the 
DuUin  Hospitcd  Reports  iov  1826,  a  considerable  number  has 
been  recorded,  so  that  in  1885  Bernays  was  enabled  to 
collect  122   cases  (N.  Y.  Med.  Record).   They  may  occur  at 


MULTILOCULAU    CYSTS. 


193 


any  age,  but  most  frequently  about  the  twentieth  year. 
They  are  more  often  met  with  in  the  lower  than  in  the 
upper  jaw  in  the  proportion  of  1 1  to  i.  They  are  of  slow 
growth,  have  very  little  tendency  to  implicate  surrounding 
parts  or  the  neighbouring  lymphatic  glands,  and,  if  com- 
pletely removed,  rarely  recur,  and  still  more  rarely  become 
disseminated  through  the  system.  Their  comparative 
innocence  is  probably  explained  by  the  bony  capsule 
forming   their  boundary,  by  their  low  degree  of  vascularity, 

Fig.  75. 


and  by  the  remarkable  tendency  of  the  epithelial  cells  com- 
posing them  to  undergo  degenerative  changes. 

Multilocular  cysts  may  contain  other  cysts  within  them, 
but  this  condition  must  be  a  rare  one,  for  I  can  find  only 
two  examples  of  it.  One  was  a  congenital  cystic  tumour  in 
an  infant  of  six  months,  who  was  under  Mr.  Coote's  care  in 
1 8  6 1 ,  and  of  which  the  following  brief  facts  are  extracted 
from  the  Lancet  of  Aug.  31st,  1861  :  "The  right  half  of 
the  lower  jaw  was  enormously  enlarged,  and  occupied  a 
prominent  position  in  the  neck,  extending  downwards  as  far 
as  the  chest.  It  appeared  to  invade  the  entire  bone,  but 
was  really  confined  to  the  right  side.     Its  increase  had  been 

IS 


194  CYSTS    OF    THE    JAWS. 

rapid  since  birth,  and  as  it  was  still  enlarging  it  became 
necessary  to  do  something  to  afford  a  chance  for  life,  as,  if 
left  alone,  suffocation  would  have  ensued,  in  a  short  time. 
Accordingly,  chloroform  being  given,  an  incision  was  made 
by  Mr.  Coote  upon  its  outer  part,  and  a  thin  shell  of  the  . 
expanded  jawbone  reached.  This  was  opened,  and  the 
interior  was  found  to  be  filled  with  a  regular  nest  of  cysts, 
one  placed  within  the  other,  all  of  which  were  removed,  and 
the  cavity  closed  with  lint.  Very  little  blood  was  lost 
during  the  operation,  and  for  a  few  days  afterwards  the  child 
improved  very  much  in  health,  although  necessarily  weak, 
and  the  great  swelling  of  the  neck  was  much  diminished. 
Suppuration  became  freely  established,  and  the  drain  shortly 
after  began  to  tell  upon  the  system,  for  the  child  became 
weaker  and  weaker,  although  well  supplied  with  wine  and 
good  nourishment,  and  finally  died  from  exhaustion." 

The  other  instance  is  given  by  Mr.  Syme  (Lancet,  March 
loth,  1855),  who  quotes  the  case  of  a  woman  having  a 
large  cystic  tumour  of  the  lower  jaw,  in  whom  he  three  times 
opened  the  cyst  and  stuffed  it,  with  temporary  benefit.  He 
was  obliged  eventually,  however  (five  years  after  the  first 
operation),  to  remove  one-half  of  the  bone,  when  the  cyst 
was  found  to  be  compound,  there  being  four  cavities,  the 
walls  of  which  were  studded  with  smaller  cysts. 

Very  considerable  alteration  in  the  form  of  the  maxilla 
may  be  produced  by  multilocular  cysts,  of  which  a  good 
example  is  seen  in  the  drawing  (Fig.  yG)  from  a  macer- 
ated specimen  in  St.  Bartholomew's  Museum.  Here  the 
bone  is  irregularly  expanded  in  great  part  to  form  septa 
between  the  cysts.  These,  which  were  independent  of  one 
another,  had  their  origin  in  the  interior  of  the  bone,  were 
lined  by  a  highly  vascular  membrane,  and  contained  thin 
serous,  or  grumous,  blood-tinged  fluid.  The  walls  of  some 
of  the  cysts  were  thin  and  yielding,  but  others  were  thick 
and  resisting,  and  this  was  particularly  the  case  with  the 
most  posterior  cyst  on  the  left  side,  which  had  pressed 
upon  and  caused  absorption  of  the  left  ramus  and  coronoid 
process.     The   preparation  was  taken  after  death  from  an 


SKELETON    OF    CYSTIC    JAW. 


19i 


old  man,  aged  seventy-five,  who  had  noticed  the  enlargement 
for  five  years,  when  he  came  under  Mr,  Coote's  care  in  St. 
Bartholomew's  Hospital  in  185  7.  The  following  brief  ac- 
count of  the  case  is  taken  from  the  Lancet  of  Oct.  loth, 
1857:  "The  origin  of  the  affection  Mr.  Coote  attributed 
to  the  irritation  produced  by  the  stumps  of  decayed  teeth. 
He  punctured  some  of  these  cysts  with  a  trocar,  and  gave 
exit  to  a  sero-purulent  fluid  from  one,  and  fluid  like  the  white 

Fig.  76. 


of  egg  from  two  others.  On  the  5  th  of  September  he  pulled 
out  a  couple  of  bodies  of  teeth,  with  scarcely  any  remains  of 
fangs,  but  in  their  stead  some  irregular  fibrous-like  projec- 
tions. The  removal  of  these  permitted  the  flow  of  a  sero- 
albuminous  fluid,  the  teeth  having  acted  like  stoppers.  Since 
the  man  had  been  in  hospital,  the  size  of  the  tumour  had 
most  certainly  diminished  one-third  under  the  plan  of  treat- 
ment of  puncturing.  The  age  of  the  patient  precluded  the 
possibility  of  attempting  any  more  severe  measures  than 
those  already  adopted.      On  the  2  ist  the  swelling  had  some- 


196 


CYSTS    OF    THE    JAWS. 


what  increased,  and  three  or  four  of  the  cysts  were  again 
punctured,  with  the  discharge  of  a  thick,  clear,  yellow  fluid, 
and  several  of  these  were  run  into  one  internally.  This  was 
done  under  partial  anaesthesia  from  chloroform.  One  of  the 
cysts  discharged  a  good  deal  in  the  mouth ;  this  was  partly 
swallowed,  and  had  caused  indigestion." 

Fig.  77. 


i...::o/ 


A,  Canine  ;  B,  Second  molar  ;  c,  Anterior  portion  of  dental  nerve  ;  d,  Ee- 
mains  of  the  base  of  horizontal  branch  of  jaw  excavated  on  its  upper 
surface,  on  which  lay  the  tumour. 

In  St.  Mary's  Hospital  Museum  is  a  valuable  recent  spe- 
cimen of  the  same  disease,  removed  by  Mr.  Lane.  Here 
the  growth  was  of  seven  years'  duration,  and  involved  the 
left  side  of  the  body  of  the  lower  jaw.  A  longitudinal  section 
shows  the  cystic  structure,  the  cells  of  which  were  filled  with 
dark  gelatinous  fluid,  and  occupied  the  whole  thickness  of 
the  bone. 


MULTILOCULAIl    CYSTS. 


197 


The  cells  may,  however,  be  of  much  smaller  size  ;  thus, 
Dr.  Eobert  Adams  records,  in  the  DMin  Hospital  Gazette 
for  185  7,  the  case  of  a  man  from  whom  he  removed  a  por- 
tion of  the  body  of  the  jaw  from  the  symphysis  to  the  molar 
teeth,  about  two  inches  in  length.  "  The  mucous  membrane 
covering  it  was  here  and  there  raised  into  small  rounded 
eminences  of  the  size  of  peas,  though  some  were  larger  and 

Fig.  78. 


purple  in  colour  (Fig.  yy).  The  tumour  was  composed  of 
bony  cells  of  a  texture  as  fine  as  the  ethmoid  bone.  The 
cells  generally  were  of  such  a  size  that  each  might  be  capable 
of  receiving  within  it  a  garden  pea.  They  communicated  with 
each  other,  and  amounted  to  no  less  than  twenty-six  in 
number.  They  were  all  lined  by  a  pulpy,  very  red,  vascular 
membrane,  and  contained  an  albuminous  fluid  tinged  of  a 
reddish  colour,  apparently  from  blood  held  dissolved  in  it." 
Again,  in  cases  of  long-standing  disease  the  cysts  become 


198  CYSTS    OF    THE    JAWS. 

gi'eatly  distended,  and  tlie  septa,  in  great  part,  absorbed,  so 
that  the  cysts  communicate  very  freely. 

Of  this  kind  was  a  tumour  (Fig.  78)  removed  by  Mr.  Cusack, 
in  1826,  from  a  woman  named  Kenny,  whose  case  will  be 
found  in  detail  in  Mr.  Cusack's  well-known  essay  in  the 
Duhlin  Hospitcd  Reports,  vol.  iv.  Dr.  Adams,  in  his  paper 
already  referred  to,  supplies  an  account  of  the  tumour  in 
this  case.  "  The  portion  of  bone  removed  comprises  the 
entire  right  half  of  the  lower  jaw.  The  horizontal  ramus  is 
expanded  into  an  oblong  hollow  shell  with  bony  walls,  and 
its  interior  is  subdivided  into  many  cells  of  various  sizes, 
which  are  all  lined  by  a  fine  polished  membrane,  and  com- 
municate freely  with  each  other." 

Miology  and  Pathology. — In  considering  the  mode  of 
origin  of  multilocular  cysts  we  meet  with  even  a  greater 
diversity  of  opinion  than  in  the  case  of  dental  and  denti- 
gerous  cysts. 

Magitot  looks  upon  them  as  formed  by  the  fusion  of 
several  dentigerous  cysts,  or  by  a  single  dentigerous  cyst 
which  has  later  on  become  subdivided. 

Falkson  published  a  case  in  the  Archiv  filr  Path.  Anat., 
1879,  in  which  he  had  very  carefully  examined  the  micro- 
scopic structure  of  the  tumour,  and  was  led  to  the  con- 
clusion that  it  had  originated  in  an  abnormal  development  of 
the  enamel  organ.  Soon  afterwards  Bryk  published  a  very 
similar  case,  and  came  to  the  same  conclusion  as  Falkson. 

In  an  interesting  lecture  given  by  Mr.  Frederick  Eve  at 
the  College  of  Surgeons  in  1882,  and  published  in  the  Prit. 
Med.  Journ.  for  1883,  an  entirely  new  theory  is  advanced, 
Mr.  Eve  believes  that  so  far  from  multilocular  cysts 
having  a  dental  origin,  they  are  produced  by  an  ingrowth 
of  the  epithelium  of  the  gum. 

"  After  repeated  examinations,  I  have  been  able  to  observe, 
in  several  specimens,  appearances  distinctly  indicating  that 
they  originate  by  an  ingrowth  of  the  epithelium  of  the 
gum.  Sections  of  a  tumour  of  the  superior  maxilla  showed 
pear-shaped  ingrowths  of  epithelium,  connected  with  the 
epithelium  of  the  gum  by  their  narrow  extremities.     The 


PATHOLOGY    OF    MULTILOCULAR    CYSTS.  199 

cells  composing  them  had  completely  undergone  degenera- 
tion except  at  the  periphery,  and  two  similar  ingrowths  were 
continuous  with  the  mass  of  the  tumour." 

Many  pathologists  felt  that  it  was  difficult  to  ascribe  this 
mode  of  origin  to  tumours,  originating  in  the  substance  of 
the  jaw,  with  the  epithelium,  of  the  gum  quite  intact  over 
the  tumour.  Again,  it  is  well  known  that  epithelium  will 
often  begin  to  proliferate,  when  irritated  by  the  proximity 
of  chronic  inflammation  or  of  a  new  growth. 

Within  two  years  of  the  publication  of  Eve's  researches, 
Malassez  announced  that  he  had  found  in  maxillae  of 
adults,  groups  of  epithelial  cells  in  the  neighbourhood  of  the 
teeth,  debris  Spithdiaiix  paradenfcdres  (Archiv.  de  Physiol., 
1885).  This  discovery  confirmed  strongly  Eve's  views  regard- 
ing the  epitheliomatous  nature  of  these  growths,  and  explained 
how  such  a  tumour  might  originate  at  some  little  distance 
from  the  gum,  and  without  involving  it  until  late  in  the 
course  of  the  disease. 

Malassez  considers  that  multilocular  cystic  tumours  have 
a  mode  of  origin  similar  to  that  of  dental  and  dentigerous 
cysts,  ascribing  them  to  an  overgrowth  of  the  rudimentary 
paradental  epithelium  (see  p.  172). 

In  conclusion,  the  consensus  of  opinion  is  certainly  in 
favour  of  adopting  Eve's  views  that  multilocular  cysts  are 
neoplasms  of  an  epitheliomatous  nature.  In  what  par- 
ticular kind  of  epithelium  the  growth  originates  is  by  no 
means  certain.  On  the  whole,  it  is  most  probable  that  they 
originate  in  connection  with  the  ingrowth  of  epithelium 
which  forms  the  enamel  organ.  It  is  quite  possible,  therefore, 
that  dental  cysts,  dentigerous  cysts,  and  multilocular  cysts 
have  a  similar  mode  of  origin.  The  exciting  cause  of  this 
activity  of  the  epithelial  structure  is  probably  to  be  found 
in  diseases  of  the  teeth,  especially  caries. 

The  microscopic  character  of  the  solid  material  found 
more  or  less  in  all  cases  of  multilocular  cyst  is  well  given 
in  the  following  report  by  Mr.  Eve  upon  a  very  well-marked 
recent  specimen  of  the  disease,  contributed  to  the  St.  Bar- 
tholomew's Hospital  Museum  by  Mr.  Keetley  :  "  The  solid 


200  CYSTS    OF   THE    JAWS. 

portion  of  the  tumour  was  composed  of  columns  of  cells  and 
nuclei  of  the  epithelial  type,  which,  when  cut  transversely, 
presented  the  appearance  of  alveoli ;  similar  small  columns 
branched  out  from  the  side  of  the  larger.  The  cells  in  the 
centre  of  the  columns  had  in  many  places  undergone  a  colloid 
change,  and  by  the  complete  metamorphosis  of  the  cells  the 
cysts  were  formed.  From  the  buccal  mucous  membrane 
covering  the  tumour  in  certain  parts,  club-shaped  and  branch- 
ing cylinders  extended  down  from  the  deep  stratum  of  the 
epithelium,  as  in  the  ordinary  formation  of  epithelial  cancer." 
Mr.  Eve  has  found  precisely  the  same  characters  in  twelve 
specimens  of  multiiocular  cystic  tumour  he  has  examined, 
one  of  the  most  marked  being  a  tumour  of  the  upper  jaw 
removed  by  Mr.  Listen  in  1836,  and  referred  to  in  his  paper 
in  the  Medico- Chirurgical  Transactions,  vol.  xx,  the  tumour 
being  now  in  the  College  of  Surgeons'  Museum. 

To  show  the  identity  of  the  foregoing  with  the  tumours 
hitherto  classed  among  the  "  cystic  sarcomata,"  I  may  quote 
the  description  of  the  microscopic  appearances  of  a  tumour  of 
the  latter  kind  removed  by  myself,  in  1871,  from  a  patient 
aged  twenty -two,  whose  portrait  before  and  after  the  opera- 
tion is  given  in  Figs.  79  and  80 :  "  The  tumour  was  composed 
microscopically  of  straight  or  tortuous  columns  of  epithelial 
cells,  those  forming  the  margin  being  elongated  or  cylindrical 
and  radiating  towards  the  centre.  At  the  margin  of  the  small 
ulcerated  opening  in  the  gum,  papillary  processes  extended 
downwards  from  the  deep  stratum  of  the  epithelium,  and 
were  continuous  with  the  columns  forming  the  tumour." 
The  half  of  this  tumour,  deposited  in  the  Museum  of  Univer- 
sity College,  is  described  in  the  valuable  catalogue  by  the  late 
Mr.  Marcus  Beck  as  a  "  gland-like  tumour  of  bone,"  and  its 
structure  is  identical  with  that  of  a  tumour  described  by  Mr. 
Wagstaffe  in  the  Pathological  Society's  Transactions,  vol.  xxii. 
Mr.  Wagstaffe  found  that  the  growth  was  composed  of 
innumerable  cysts  and  a  solid  matrix,  through  which  a  certain 
amount  of  bone  was  scattered;  that  the  cysts  were  lined  by  a 
layer  of  large  globular  epithelium ;  that  into  the  interior 
of   the   larger   cysts    other    smaller    cysts    projected,  these 


CYSTIC    SARCOMA. 


201 


endogenous  cysts  taking  their  origin  in  the  epithelial  lining, 
and  not  in  the  matrix  of  the  growth.  Other  cysts  were  also 
freely  scattered  throughout  the  structure,  but  the  endogenous 
formations  were  so  marked  that  they  could  be  discovered  as 
little  balls  by  the  naked  eye,  and  removed  for  examination  by 
the  point  of  a  needle.  The  solid  structure  consisted  of  a 
very  peculiar  arrangement  of  what  appeared  to  be  acini   or 


Fig.  79. 


Fig.  80. 


cylinders  of  closely-packed  cells,  supported  by  a  fibro-nucleated 
matrix.  These  acini,  or  rods,  in  many  places  gave  the  appear- 
ance of  tubes  from  the  arrangement  of  their  component  cells, 
which  resembled  very  curiously  that  of  columnar  epithelium, 
or  of  the  epithelium  of  glani  follicles.  The  cut  ends,  how- 
ever, showed  no  central  canal.  The  constituents  of  these  rods 
were  nuclei  embedded  in  plastic  matter,  and  these  separated 
by  manipulation  into  small  tailed  or  so-called  spindle  cells, 
of  similar  size  and  character  to  the  corpuscles  of  an  ordinary 
sarcoma. 


202  CYSTS    OF    THE    JAWS. 

The  contents  of  these  cysts  vary  in  consistency  and  colour ; 
in  some  cases  being  clear  and  limpid,  in  others  almost 
gelatinous  and  of  a  dark  colour. 

My  attention  was  first  directed  to  the  fact  that  multilocular 
cystic  disease  is  not  always  a  simple  local  ailment,  by  the 
case  of  a  patient  who  was  able  to  give  me  a  "  Thirty-five 
years  history  of  a  maxillary  tumour,"  which  I  communicated 
in  1880  to  the  Association  of  Surgeons  practising  Dental 
Surgery  {British  Medical  Journal,  May  22nd,  1880).  The 
patient,  when  he  first  came  under  my  notice  in  1877,  was  a 
healthy  country  gentleman,  who  said  that,  as  long  as  he  could 
remember,  there  had  been  some  enlargement  of  the  right  side 
of  the  lower  jaw.  In  1845  this  enlargement  increased  very 
rapidly,  and  in  1847  Sir  W.  Fergusson  removed  a  tumour  of 
the  right  side,  sawing  through  the  ramus  horizontally,  and 
the  body  of  the  jaw  close  to  the  right  canine  tooth.  The 
tumour  was  apparently  of  a  fibroid  character,  having  a  large 
cyst  developed  in  it,  and  is  now  in  the  Museum  of  King's 
College.  He  continued  in  good  health  for  fifteen  years,  and 
then  noticed  the  formation  of  a  cyst  in  the  incisor  region, 
which  had  frequently  been  tapped  by  Sir  W.  Fergusson.  In 
July,  1877,  I  found  cystic  disease  of  the  left  side  of  the  body 
of  the  jaw  extending  to  the  molar  region,  and  operated^  by 
extracting  all  the  teeth,  opening  up  the  cysts  freely,  and 
clearing  out  some  solid  growth  with  the  gouge.  From  this 
the  patient  made  a  good  recovery,  with  considerable  con- 
solidation of  the  bone,  but,  in  the  following  November,  one 
cyst  was  found  to  have  developed  anew  in  the  incisor  region, 
and  this  was  treated  in  a  similar  manner.  A  year  later  a 
fresh  development  of  cysts  had  taken  place  and  the  operation 
was  repeated  with  a  good  result,  so  that  in  February,  1879, 
the  jaw  was  completely  consolidated,  and  the  patient  was 
advised  to  have  some  artificial  teeth  fitted.  In  November, 
1879,  the  patient  reappeared  with  a  large  solid  tumour,  in- 
volving the  left  side  of  the  body  of  the  jaw,  which,  noticed 
first  in  June,  had  grown  rapidly  of  late,  and  now  involved 
the  skin  for  an  area  of  a  square  inch.  On  December  2nd  I 
removed  the  tumour  by  sawing  through  the  bone  immediately 


MULTILOCULAR    CYSTIC    TUMOUR.  203 

in  front  of  the  left  masseter,  and  also  removed  a  piece  of 
infiltrated  skin  from  the  left  of  the  median  line.  The  wound 
was  brought  together  with  harelip  pins  and  sutures,  and  only 
one  artery  (facial)  was  ligatured.  The  patient  made  a  good 
recovery,  took  food  with  a  spoon,  and  was  able  to  talk  intel- 
ligibly after  the  first  week,  although  deprived  now  of  the 
entire  body  of  the  jaw.  The  lower  end  of  the  wound  being 
left  open  afforded  a  thorough  drain  for  discharge.  The 
patient  returned  early  in  February,  when  the  skin  near  the 
wound  was  found  to  be  increasingly  infiltrated,  and  a  tumour 
of  the  size  of  an  orange  was  found  beneath  the  right  deltoid. 
He  had  strained  the  right  arm  in  getting  into  a  hip  bath,  but 
was  quite  clear  that  the  humerus  had  not  been  struck.  The 
tumour  was  x^ainful,  but  the  bone  was  sound,  the  head  moving 
with  the  shaft.  A  week  later  the  patient  was  found  to  have 
a  tumour  in  the  pelvis,  pressing  upon  the  rectum,  and  springing 
from  the  interior  of  the  right  innominate  bone.  From  this 
time  he  gradually  lost  strength,  and  died  at  the  end  of  March. 
The  second  tumour  was  pronounced  by  Mr.  Doran  to  be  a 
round- celled  sarcoma,  and  the  same  growth  was  found  in 
the  piece  of  skin  which  was  removed.  The  earlier  tumour 
appeared  to  be  a  fibroid  or  a  spindle-celled  sarcoma.  No 
post-mortem  examination  of  the  internal  growths  could  be 
obtained. 

The  specimen  is  preserved  in  the  Museum  of  the  College 
of  Surgeons,  and  Mr.  Eve's  further  examination  shows  that 
the  upper  portion  of  the  tumour  contains  isolated  masses,  com- 
posed of  tortuous  closely-crowded  columns  of  small  epithelial 
cells. 

The  second  case  bearing  upon  the  same  question  was  in  a 
woman  of  forty-four,  who  was  admitted  into  University 
College  Hospital,  on  November  3rd,  1875,  with  the  following 
history  :  About  nine  years  before,  the  patient  first  noticed 
a  lump  of  the  size  of  a  pea  beneath  the  tongue,  on  the  right 
side,  which  gave  her  some  pain,  and  for  which  a  tooth  was 
extracted.  From  that  time  she  had  a  succession  of  ab- 
scesses (?)  in  the  lower  jaw,  some  of  which  discharged  in  the 
mouth,  and  one  externally,  and  for  which  she  had  had  several 


204 


CYSTS    OF    THE    JAWS. 


teeth  extracted.  Dr.  Parsons,  of  Dover,  had  sent  her  to  me 
three  years  before,  and  I  then  recommended  her  to  come  into 
the  hospital ;  but  she  declined,  and  went  on  with  a  steadily 
increasing  tumour  of  the  lower  jaw  on  the  right  side.  About 
nine  months  before  admission  the  tumour  seems  to  have  begun 
to  increase  with  some  rapidity,  and  within  the  last  two  months 
the  following  characteristic  event  happened.  While  eating, 
the  patient  felt  a  sudden  crack  in  the  lower  jaw,  and  this 

Fig.  8 1. 


occurred  twice  in  the  same  week  ;  and  upon  each  occasion  she 
felt  great  pain  in  the  floor  of  the  mouth  and  upon  moving  the 
tongue.  Upon  admission  there  was  really  very  little  to  be 
seen  externally,  and  a  photograph  taken  at  the  time  shows 
that,  excepting  a  very  small  projection  beneath  the  skin  in 
front  of  the  angle  of  the  jaw,  there  was  nothing  to  call  atten- 
tion to  the  patient's  face.  On  looking  into  the  mouth,  how- 
ever, the  tumour  was  at  once  obvious,  and  is  seen  in  a  cast 
taken  from  the  jaw  at  that  time  (Fig.  8i).  The  right  side  of 
the  lower  jaw  is  seen  to  be  greatly  expanded  from  immediately 
in  front  of  the  ramus  to  beyond  the  median  line,  the  tumour 


MULTILOCULAU    CYSTIC    TUMOUK.  205 

measuring  two  inches  across  at  the  broadest  part,  and  reach- 
ing under  the  tongue.  Its  surface  was  lobulated  and  rounded, 
firm  and  osseous  in  the  greater  part,  but  yielding  distinctly 
on  pressure  in  two  or  three  places.  The  mucous  membrane 
was  entire  over  the  tumour,  except  at  one  ]3oint  where  there 
was  an  opening,  from  which  a  discharge  constantly  exuded. 
The  incisor  teeth,  of  the  right  side  were  displaced  over  to  the 
opposite  side,  and  were  loose.  The  central  incisor  of  the 
left  side  was  displaced  completely  in  front  of  the  other  teeth. 
The  left  canine  and  bicuspids  were  firmly  fixed.  Notwith- 
standing the  size  of  the  tumour,  the  outline  of  the  lower 
border  of  the  jaw  was  scarcely  interfered  with,  the  disease 
being  mainly  confined  to  the  alveolar  portion  of  the  bone ; 
and  I,  therefore,  decided  to  operate  from  within  the  mouth, 
so  as  to  avoid,  if  possible,  all  external  scar. 

On  November  loth  the  patient  was  put  under  chloroform, 
and,  a  gag  having  been  introduced  on  the  left  side,  I  first 
extracted  the  four  incisors,  and  then  made  a  free  incision 
with  a  stout  scalpel  along  the  upper  surface  of  the  tumour, 
cutting  easily  through  the  thin  bone  and  thick  membrane 
forming  its  upper  wall,  A  quantity  of  dark-coloured  cystic 
fluid  at  once  escaped,  and  I  then  cleared  out  the  semi-solid 
contents  with  the  finger  and  gouge.  The  finger  introduced 
into  the  cavity  passed  completely  under  the  canine  and 
bicuspid  teeth  of  the  opposite  side  without  disturbing  them. 
I  next  cut  away  a  portion  of  the  cyst- wall  with  scissors,  and 
crushed  together  the  remainder,  as  far  as  I  could,  with  my 
fingers  and  thumb.  The  actual  cautery  was  applied  to  one 
spouting  vessel  in  the  margin  of  the  alveolus,  and  the  cavity 
was  stuffed  with  lint  dipped  in  a  solution  of  chloride  of  zinc 
(twenty  grains  to  the  ounce). 

The  patient  had  very  little  constitutional  disturbance  ;  the 
plugs  were  gradually  removed  from  the  cavity  of  the  jaw, 
which  was  carefully  syringed  out  frequently  with  Condy's 
fluid,  and  soon  began  to  granulate  and  fill  up.  She  was 
discharged  a  month  after  the  operation,  when  the  two  plates 
of  the  lower  jaw  had  come  together,  and  the  cavity  was  filled 
up  almost  completely  by  granulation-tissue,  there  being  only 


206 


CYSTS    OF  THE    JAWS. 


a  shallow  cavity  half  an  inch  long  still  to  be  filled  up  mid- 
way between  the  angle  and  the  symphysis. 

This  patient  again  presented  herself  in  October,  1878, 
nearly  three  years  after  the  first  operation,  with  a  recurrence 
of  the  cysts,  which  were  treated  again  by  gouging  and  crush- 
ing in.  In  August,  1882,  she  again  appeared  with  a  formid- 
able tumour  of  the  lower  jaw,  which  had  already  sprouted 
through  the  chin  at  more  than  one  point  (Fig.  82).     There 

Fig.  82. 


could  be  no  question  now  of  the  necessity  for  excising  the 
portion  of  jaw  involved,  and  this  I  accordingly  did,  removing 
from  an  inch  in  front  of  the  angle  on  the  left  side  to  the 
right  temporo-maxillary  articulation.  The  patient  made  a 
good  recovery,  and  has  remained  well. 

As  a  further  contribution  to  this  subject  I  may  refer  again 
to  the  case  of  "  cystic  sarcoma "  described  at  p.  200,  and 
illustrated  by  Figs.  79  and  80,  where  I  left  in  situ  the  coronoid 
process  and  condyle  with  part  of  the  posterior  border  of  the 
lower  jaw,  in  June,  1872.  In  October,  1883,  this  patient 
reappeared  in  the  condition  shown  in  F'ig.  83,  with  a  typical 


TKEATMENT    OF    CYSTS    IN    LOWER   JAW. 


207 


epithelial  ulcer  of  the  skiu  of  the  cheek.  On  proceeding  to 
cut  this  away  freely,  I  found  that  it  was  attached  to  the 
remains  of  the  lower  jaw,  which  I  was  obliged  to  remove  in 
order  to  get  rid  of  the  whole  of  the  growth.  One-half  of  this 
secondary  growth  is  in  the  Museum  of  the  College  of  Surgeons, 
and  its  microscopic  characters  correspond  precisely  to  those 
of  the  former  growth,  p.  200. 

There  can,  then,  I  think,  be  no  doubt  that  under  the  term 

Fig.  83. 


"  multilocular  cystic  epithelial  tumour,"  as  proposed  by  Mr. 
Eve,  we  may  include  the  old  multilocular  cysts  and  cystic 
sarcomata,  both  having  a  distinct  tendency  to  be  reproduced 
locally,  and  in  certain  cases  to  become  disseminated. 

Treatment.  —  Mr.  Butcher,  of  Dublin,  for  many  years 
treated  cases  of  multilocular  cyst  of  the  lower  jaw  through 
the  mouth,  by  dividing  the  mucous  membrane  over  the  cyst 
freely,  and  then  with  gouge  and  bone-forceps  removing  the 
expanded  external  plate  of  the  bone,  with  the  contents  and 
lining  membrane  of  the  cyst.  In  this  operation  the  teeth 
are  interfered   with   as   little    as   possible,    and   appear   to 


208  CYSTS    OF    THE    JAWS. 

remain  firm.  Granulations  rapidly  spring  up  from  the 
denuded  bone,  and  fill  the  wound  made  in  the  mouth ; 
the  cheek  resumes  its  ordinary  appearance,  and  no 
deformity  or  scar  is  left.  In  his  work  on  "  Operative 
and  Conservative  Surgery,"  Mr.  Butcher  narrates  three 
cases  treated  in  this  manner,  and  remarks,  that  "  the  pro- 
ceeding according  to  this  plan  is  troublesome  and  difficult, 
but  its  value  to  the  patient  in  having  no  deformity  left  is 
priceless."  A  valuable  caution  is  here  given  respecting  the 
facial  artery,  which  might,  without  care,  be  divided  from 
within  the  mouth  in  a  position  where  it  would  be  very 
difficult  to  secure  it.  Mr.  Butcher  also  narrates  and  gives 
a  drawing  of  a  case  in  which,  finding  the  disease  too  exten- 
sive to  be  treated  from  the  mouth,  he  adopted  Dupuytren's 
external  incision,  and  then  levelled  the  projection  to  the 
line  of  the  healthy  bone  with  the  best  results,  the  incision 
being  completely  hidden  behind  the  bone. 

Dr.  Mason  Warren  has  also  (Boston  Medical  and  Surgical 
Journal,  1866)  written  upon  the  treatment  of  cysts  of  the 
jaws,  and  strongly  recommends  a  milder  and  even  more 
conservative  practice  than  that  followed  by  Mr.  Butcher, 
which  he  thus  summarizes  :  "  The  treatment  consisted  in 
the  puncture  of  the  sac  within  the  mouth,  evacuating  its 
contents,  and  at  the  same  time  obliterating  its  cavity  by 
crushing  in  its  walls  ;  and  lastly,  in  keeping  up,  by  in- 
jections, &c.,  a  sufficient  degree  of  irritation  to  favour  the 
deposition  of  new  bone." 

I  have  now  treated  a  considerable  number  of  simple  and 
multilocular  cysts  by  Mr.  Butcher's  method,  and,  as  has 
been  noted,  with  recurrence  in  at  least  two  of  the  latter. 
Mr.  Butcher  does  not  appear  to  have  met  with  further 
trouble  in  his  cases,  and  this  may  depend  upon  his  "  carry- 
ing out  the  gouging  fearlessly  and  far  wide  of  the  disease." 
I  should  in  future  be  guided  by  the  age  of  the  patient,  and 
the  amount  of  solid  material  found  in  the  cysts.  In  young 
persons  with  cysts  having  fluid  contents  and  little  growth 
in  the  bone,  I  should  be  still  inclined  to  adopt  palliative 
measures  and  to  gouge  very  freely,  carefully  watching  the 


TREATMENT   OF    MULTILOCULAR    CYSTS.  209 

case  with  a  view  to  a  more  radical  proceeding,  should 
further  development  take  place.  In  cases  of  much  solid 
deposit  in  connection  with  multilocular  cysts,  and  still  more 
in  cases  of  solid  tumour  with  one  or  more  large  cysts,  there 
should,  I  think,  be  no  doubt  as  to  the  removal  of  one-half 
or  more  of  the  lower  jaw,  or  of  any  portion  of  the  upper  jaw 
involved. 

In  his  well-known  essay  on  "  Diseases  of  the  Jaw  "  (Cal- 
cutta, 1844)  Mr.  O'Shaughnessy  narrates  a  case  of  large 
cystic  disease  of  the  jaw  which  would  appear  to  have  been 
originally  a  multilocular  cyst,  in  which  the  septa  had 
undergone  almost  complete  absorption,  so  that  "  the  tumour 
after  maceration  was  found  to  be  a  hollow  shell  of  bone, 
containing  in  its  centre  a  quantity  of  a  gelatinous  and 
fluid  substance,  and  a  few  particles  of  bone  like  pieces 
of  honeycomb.  The  coronoid  process  was  hollowed  out 
like  the  rest  of  the  bone,  and  so  thick  that  it  must  have 
completely  filled  the  temporal  fossa,  which  accounts  for  the 
difficulty  experienced  in  trying  to  divide  the  temporal 
muscle." 

This  difficulty  of  clearing  the  coronoid  process  has  been 
noticed  also  in  cases  where  the  bone  has  been  expanded  by 
a  solid  growth  within  it,  or  is  wedged  in  by  a  portion  of 
tumour  springing  from  the  ramus.  Dr.  Eobert  Adams 
narrates  (DuMin  Hospital  Gazette,  April  i  5th,  1 857)  a  case  of 
the  former  kind,  and  Mr.  Cusack  (Duhlin  Hospital  Reports, 
vol.  iv)  two  cases  of  the  latter,  in  all  of  which  the  difficulty 
was  overcome  by  sawing  through  the  ramus  of  the  jaw  and 
subsequently  removing  the  coronoid  process  and  condyle. 
The  possible  occurrence  of  this  difficulty  is  to  be  borne  in 
mind  in  cases  of  cystic  growth  requiring  disarticulation  ;  and 
I  experienced  it  in  the  case  of  large  "  cystic-sarcoma," 
already  referred  to. 

The  difficulty  is  best  got  over  by  the  division  of  the 
coronoid  process  with  the  bone-forceps,  and  the  piece  thus 
cut  off  should  afterwards  be  dissected  out. 


CHAPTEE  XIII. 

ODONTOMATA  AND  CEETAIN  IREEGULAKITIES  OF  TPIE  TEETH. 

The  meaning  of  the  term  odontoma  in  its  broadest  patlw- 
logical  sense  has  already  been  discussed  in  the  Chapter 
on  "  Cysts  of  the  Jaws,"  and  it  was  there  pointed  out  that, 
for  the  present  at  any  rate,  it  would  be  more  convenient  to 
restrict  the  term  to  its  generally  accepted  clinical  signifi- 
cation— i.e.,  a  tumour  composed  of  enamel  or  dentine  or 
cementum,  or  of  a  combination  in  varying  proportions 
of  any  of  these  three  elements.  It  seems  most  probable 
that,  in  the  human  subject,  all  odontomata  originate  in 
abnormal  development  of  the  dental  papilla.  In  the  lower 
animals,  however,  this  is  not  the  case.  Bland  Sutton  has 
pointed  out  that  tumours  composed  of  cementum  only, 
eementomata  as  they  are  called,  are  very  common  in  lower 
animals,  especially  in  the  Ungulata ;  and  this  cementum  is 
developed  from  the  wall  of  the  dental  follicle,  not  from  the 
dental  pajnlla.  The  same  authority  claims  that  one  case, 
at  least,  from  the  human  subject  belongs  to  the  category  of 
follicular  eementomata.  This  case  is  described  by  Dr. 
Forget  in  his  classical  work  on  "Dental  Anomalies." 
It  occurred  in  the  practice  of  M.  Maisonneuve,  and  in  the 
person  of  a  man  aged  forty.  The  tumom^  occupied  the  left 
side  of  the  lower  jaw,  causing  both  its  surfaces  to  project, 
but  especially  the  outer.  At  the  smaller  end  of  the  tumour 
was  a  decayed  molar  tooth,  and  upon  extracting  this  the 
tumour  came  away  with  it.  The  growth,  which  was  larger 
than  a  pigeon's  egg,  was  attached  to  the  tooth  by  a  kind  of 
pedicle,  a  section  showing  a  line  of  separation  between 
it  and  the  root  of  the  tooth.      Under  the  microscope  the 


EADICULAR    ODONTOMATA.  211 

specimen  was  seen  to  contain  no  dentine,  but  to  consist 
exclusively  of  cementum  (Fig.  84).  On  a  careful  re- 
examination of  the  tumour,  Magitot  found  some  dentine 
in  the  central  part  of  the  mass  forming  the  boundary  of  a 
large  cavity.  It  is  doubtful,  therefore,  whether  to  look  upon 
this  case  as  a  pure  follicular  cementoma  with  remains  of 
dentine  and  pulp  cavity,  or  as  a  mixed  odontoma  consisting 
of  cementum  and  dentine. 

Fig.  84. 


Except  in  the  case  of  this  doubtful  specimen  we  cannot 
do  better  than  adopt  the  classification  suggested  by  Bland 
Sutton  for  hard  odontomata,  viz. : 

A.  Aberrations  of  the  dental  papilla. 

Eadicular  odontomata. 
a.  Dentomata. 
&.  Osteo-dentomata. 
c.   Cementomata. 

B.  Aberrations  of  the  whole  tooth-germs — i.e.,  dental 
papilla,  dental  follicle,  and  enamel  organ. 

Composite  odontomata. 

C.  Anomalous  odontomata. 

A.  Aberrations  of  the  Dental  Papilla. — The  term  radicular 
odontoma  is  applied  by  Bland  Sutton  to  "odontomata  which 
arise  after  the  crown  of  the  tooth  has  been  completed,  and 
whilst  the  roots  are  in  the  process  of  formation.  As  the 
crown  of  the  tooth,  when  once  formed,  is  unalterable,  it 
naturally  follows  that  should  the  root  develop  an  odontoma, 
enamel  cannot  enter  into  its  composition,  which,  for  the 
most  part,  would  consist  of  dentine  and  osteo-dentine  in 
varying  proportions,  these  two  tissues  being  the  result  of 


212       ODONTOMATA    AND    IRREGULAKITIES    OF    THE    TEETH. 


the  activity  of  the  papilla.  When  such  a  tumour  consists 
mainly  or  entirely  of  dentine  it  may  be  termed  a  radicular 
dcntoma.  If  osteo-dentine  preponderates,  then  the  tumour 
may  be  called  a  radicidar  osteo-dentoma ;  or,  if  cementum, 
then  it  is  a  radicular  cementomar 

A  remarkable  specimen  of  a  radicular  odontoma  in 
the  Museum  of  the  College  of  Surgeons  of  England  has 
been  especially  investigated  by  Mr,    Salter  (Guy's  Hospital 

Fig.  85. 


Fig.  86. 


Reports,  1869),  who  believes  that  the  outgrowth  is  due  to 
"  hypertrophy  and  dilatation  of  a  fang,  and  not,  as  was 
formerly  supposed,  to  hypertrophy  of  the  cementum. 
Fig.  85,  from  Mr.  Salter's  paper,  illustrates  the  structure 
of  the  tumour,  and  Fig.  86  shows  the  relation  of  the 
growth  to  the  tooth.  The  outer  layer  is  composed  of 
cementum  or  tooth  bone,  and  within  this  is  a  layer  of  true 
dentine,  which  is  wanting  below  ;  and  within  this  again  is 
the  "nucleus"  of  calcified  tooth-pulp.    This  last  is  "composed 


MR.  hare's  odontoma.  213 

of  a  confused  mass  of  bone-structure  and  dentine-structure, 
arranged  around  and  separating  an  elaborate  vascular  net- 
work of  the  same  character  as  that  of  the  dentinal  pulp." 

Almost  synchronously  with,  but  independently  of,  Salter, 
Professors  Heider  and  Wedl  (Atlas  zicr  Pathologie  der  Zdhne) 
described  a  tooth-tumour  resembling  in  many  respects  that 
at  the  College  of  Surgeons. 

In  April,  1863,  Mr.  Tomes  exhibited  to  the  Odontological 
Society  an  extraordinary  specimen  of  so-called  exostosis, 
shown  in  the  illustration  (Fig.  87),  which  I  have  been 
permitted  to  borrow  from  the  Transactions  of  the  Odontological 
Society  (vol.  iii).  It  is  really  a  radicular  odontoma,  and  is 
especially   interesting,  inasmuch  as  it  is   one   of  the   few 

Fig.  87. 


specimens  of  odontoma  removed  from  the  upper  jaw  in  the 
human  subject.  The  molar  tooth,  to  which  it  is  attached, 
was  removed  by  Mr.  Hare,  of  Limerick,  from  the  upper  jaw 
of  a  man,  aged  forty-one,  who  had  long  suffered  pain  in  the 
jaw,  from  which  a  fistulous  passage  led  through  the  cheek. 
The  growth  is  more  or  less  hollowed  out,  and  on  this  account 
it  has  been  suggested  that  it  may  possibly  be  an  instance  of 
calcified  dental  cyst.  The  specimen  has,  however,  recently 
undergone  careful  microscopic  examination  by  Mr.  Charles 
Tomes,  who  found  that  it  closely  resembled  Forget's  specimen 
already  described  (Fig.  84),  of  which  a  microscopic  section 
is  given  by  Broca.  Mr.  C.  Tomes  brought  the  preparation 
before  the  Odontological  Society  in  January,  1872,  and  has 
shown  that  the  outgrowth  is  not  connected  with  the  fangs 
of  the  tooth,  but  had  sprung  from  the  dentinal  pulp.  This 
latter  he  believes  to  have  undergone  partial  destruction 
before  becoming  calcified,  and  hence  the  cavity  formed  in 


214       ODONTOMATA   AND    lEEEGULAEITIES    OF  THE   TEETH. 

the  tumour.  {Transactions  of  th&  Odontological  Society  of 
Great  Britain,  January,  1872.)  Wliatever  its  nature,  it  must, 
from  its  size,  have  either  invaded  or  obliterated  the  antrum. 

A  case  of  radicular  odontoma  has  more  recently  been 
described  by  Windle  and  Humphrey  in  the  Journal  of 
Anatomy  and  Physiology  (vol.  xxi).  It  occurred  in  a  man 
aged  twenty-five.  He  had  a  swelling  on  the  right  side  of 
the  lower  jaw,  in  the  situation  of  the  second  molar  tooth. 
Pain  became  very  severe,  and  then  an  abscess  burst,  and  pus 
was  escaping  from  the  sinus  for  some  months.  Finally,  a  hard 
mass  became  free  and  escaped  into  his  mouth.  The  odontoma 
seemed  to  be  composed  chiefly  of  cementum,  but  this  was  not 
certain,  as  sections  of  the  tumour  could  not  be  obtained. 

Another  form  of  tumour  connected  with  a  tooth  consists 
in  an  outgrowth  from  a  more  or  less  perfect  tooth,  depending 
upon  some  modification  of  the  dentinal  pulp,  after  the  forma- 
tion of  the  dentinal  cap.  These  growths  belong  to  the 
Odontomes  coronaires  of  Broca,  and  have  been  described  as 
loarty  teeth  by  Salter.  They  occur  before  the  fang  is 
formed,  during  the  development  of  the  crown,  so  that 
cementum  cannot  enter  into  their  composition.  The  tumour 
is  situated  at  the  neck  of  the  tooth,  and  is  formed  by  an 
outgrowth  of  the  pulp,  covered  by  dentine  and  enamel.  If 
the  tumour  be  large  and  circumscribed  it  may  prevent  the 
eruption  of  the  tooth,  but  if  the  growth  be  diffused  around 
the  neck  of  the  tooth,  the  latter  may  be  erupted,  and  is  then 
known  as  a  "  warty  tooth." 

B.  Aberrations  of  the  whole  tooth-germ — i.e,  dental  papilla, 
dental  follicle,  and  enamel  organ. 

According  to  Bland  Sutton,  "  composite  odontomata  is  a 
convenient  term  to  apply  to  those  hard  tooth  tumours  which 
bear  little  or  no  resemblance  in  shape  to  teeth,  but  occur  in 
the  jaws,  and  consist  of  a  disordered  conglomeration  of 
enamel,  dentine,  and  cementum.  Such  odontomata  may  be 
considered  as  arising  from  an  abnormal  growth  of  all  the 
elements  of  a  tooth-germ — enamel  organ,  papilla,  and  folli- 
cular wall." 

I  have  been  able  to  collect  only  eleven  cases  of  composite 


COMPOSITE    ODONTOMATA.  215 

odontomata,  and  all  of  them,  with  one  exception,  occurred 
in  the  lower  jaw. 

The  first  case  was  communicated  to  the  Faculty  of 
Medicine  of  Paris  in  1809  by  M.  Oudet.  The  patient,  a 
man,  aged  twenty-five,  had  on  the  right  side  of  the  lower 
jaw  a  mass  occupying  the  position  of  the  premolar  teeth, 
which,  on  removal,  proved  to  be  composed  of  dentine  and 
enamel.     A  similar  mass  on  the  left  side  was  not  removed. 

The  second  case  occurred  some  years  back,  in  the  practice 
of  Sir  William  Fergusson,  by  whom  the  tumour  was  removed 
with  a  portion  of  the  jaw,  and  is  described  by  Mr.  Tomes 

Fig.  S8. 


("  Dental  Surgery  "),  from  whose  work  a  drawing  of  a  section 
,of  the  tumour  is  taken  (Fig.  88).  "The  second  molar  of 
the  lower  jaw  was  represented  by  an  irregularly  flattened 
mass,  composed  of  enamel,  dentine,  and  bone  derived  from 
calcification  of  remnants  of  the  dentine  pulp,  thrown  together 
without  any  definite  arrangement,  by  which  the  wisdom 
tooth  was  held  down.  The  dental  mass,  when  removed 
from  its  receptacle  in  the  bone,  presented  no  resemblance  to 
a  tooth.  Little  beads  of  enamel  here  and  there  projected 
from  the  surface,  which  was  generally  rough  and  irregular. 
The  naked-eye  appearance  of  the  section  is  accurately  given 
in  the  woodcut,  the  radiate  character  in  which  shows  the 
arrangement  of  the  component  tissues,  which,  by  the  aid  of 
the  microscope,  are  seen  at  places  to  alternate.  The 
alternation  is  mainly  effected  by  the  dentine  and  bony  tissue. 


216       ODONTOMATA    AND    lEREGULAEITIES    OF    THE    TEETH. 

and  these,  indeed,  form  the  great  bulk  of   the  mass 

The  appearances  presented,  prior  to  the  operation,  consisted 
in  enlargement  of  the  jaw  posterior  to  the  first  permanent 
molar  tooth,  with  a  hard,  brown-looking  body  projecting  but 
slightly  from  the  surface  of  the  gum.  This  projecting  por- 
tion was,  in  fact,  the  upper  surface  of  the  aberrant  tooth ; 
and  the  nodules  of  enamel  were,  for  the  most  part,  situated 
in  this  part  of  the  mass." 

The  third  case  occurred  to  Dr.  Forget  (op.  cit.),  in  the 
person  of  a  young  man,  aged  twenty,  who  presented  himself 
in  1855  with  a  disease  of  the  lower  jaw,  from  which  he  had 
suffered  since  he  was  five  years  old.  Upon  looking  into  the 
mouth,  a  round,  smooth  tumour,  hard  and  unyielding,  was 
seen  occupying  nearly  the  whole  of  the  left  side  of  the  jaw. 
None  of  the  teeth  beyond  the  first  bicuspid  were  present. 
Dr.  Eorget  removed  the  portion  of  the  jaw  involved  by 
sawing  through  it  in  front  of  the  bicuspid  tooth,  and  also 
through  the  ramus  at  the  level  of  the  inferior  dental  foramen. 
The  portion  removed  is  seen  in  the  accompanying  drawing 
(Fig.  88).  An  examination  of  the  portion  which  had  been 
removed  showed  that  the  portion  of  the  jaw  between  the 
ramus  and  the  first  bicuspid  tooth  was  converted  into  a  cavity, 
which  was  occupied  by  a  hard  oval  mass,  of  the  size  of  an 
egg,  having  an  uneven  surface  covered  here  and  there  with 
minute  tubercles,  which  were  invested  by  a  layer  of  enamel, 
penetrating  into  the  substance  of  the  bone,  and  easily  recog- 
nizable by  its  shining  appearance  and  peculiar  colour.  A 
section  of  the  tumour  showed  that  it  consisted  of  a  compact 
tissue  of  the  consistence  of  ivory,  of  a  greyish-white  colour, 
in  the  interior  of  which  it  was  possible  to  perceive,  with  the 
naked  eye,  a  kind  of  regular  arrangement  of  the  elements 
which  entered  into  its  composition.  Between  the  tumour 
and  the  osseous  cyst  was  a  thick  membrane,  apparently  of  a 
fibro-cellular  structure.  At  the  anterior  extremity  of  the 
base  of  the  tumour  was  a  depression  in  which  the  crown  of 
an  inverted  molar  tooth  was  wedged  in  between  it  and  the 
maxilla.  This  tooth  is  seen  in  Fig.  89,  c,  where  a  portion 
of  bone  has  been  cut  away ;  a  and  h  mark  portions  of  the 


COMPOSITE    ODONTOMATA. 


217 


tumour  projecting  through  the  jaw,  and  c?  is  the  second 
bicuspid  tooth  lying  below  the  first,  e. 

The  microscopic  examination  of  the  tumour  showed  it  to 
be  composed  principally  of  dentine,  with  enamel  on  the  sur- 
face and  dipping  into  the  crevices,  at  the  bottom  of  which, 
as  well  as  in  other  parts,  portions  of  cementum  were  found. 
Dr.  Forget  regards  the  case  as  one  of  fusion  and  hypertrophy 
of  the  last  two  molars. 

The  fourth  case  of  the  kind  was  brought  under  the  notice 
of  the  Odontological  Society  of  Great  Britain,  in  December, 

Fig.  89. 


1862,  by  the  late  Mr.  W.  A.  Harrison,  F.E.C.S.  The 
specimen  closely  resembled  those  already  described,  and 
came  from  the  left  side  of  the  lower  jaw  of  a  lunatic,  where 
it  occupied  the  space  between  the  incisor  and  molar  teeth. 
It  came  away  spontaneously,  leaving  a  long  deep  groove, 
large  enough  to  receive  the  last  joint  of  the  thumb,  which 
soon  granulated  and  contracted.  The  specimen  is  in  the 
Museum  of  the  Dental  Hospital,  Leicester  Square. 

The  fifth  case  is  given  in  Heider  and  Wedl's  Atlas  zur 
Pathologie  der  Zdhne,  and  closely  resembles  Mr.  Tomes'  case, 
the  second  molar  tooth  of  the  right  side  being  developed  into 
a  large  irregular  mass,  and  holding  down  the  wisdom  tooth. 
It  was  easily  removed. 


218       ODONTOMATA   AND   IRREGTJLAEITIES    OF   THE   TEETH, 

Mr.  Annandale  lias  reported  {Edinhurgh  Medical  Journal, 
Jan.  1873)  a  sixth  case  occurring  in  the  lower  jaw  of  a 
young  woman,  aged  seventeen,  who  had  never  had  any  molar 
teeth  on  the  left  side.  A  nodulated  mass,  which  somewhat 
resembled  a  piece  of  necrosed  bone,  projected  above  the  gum, 
and  was  firmly  fixed.  Mr.  Annandale  dislodged  the  growth 
and  removed  it  through  the  mouth.  It  measured  i-^  by  \\ 
inches,  and  weighed  300  grains,  and  on  section  showed  "  that 
a  cap  of  enamel,  varying  in  thickness,  was  arranged  over  a 
portion  of  the  irregular  surface  of  the  mass.  Beneath  this, 
well-formed  dentine,  forming  a  considerable  thickness,  was 
met  with ;  and  still  deeper  in  the  substance  of  the  mass,  true 
bone,  containing  lacunas,  canaliculi,  and  Haversian  canals, 
was  seen  to  be  intermingled  in  a  confused  manner  with 
portions  of  dentine,  so  as  to  form  the  substance  called  by 
histologists  "  osteo-dentine." 

The  seventh  case  occurred  in  the  practice  of  Dr.  Good- 
willie,  of  New  York,  and  is  mentioned  in  Agnew's  "  Surgery," 
vol.  ii.  It  appears  to  have  been  removed  with  the  angle  of 
the  jaw. 

An  eighth  case  was  recorded  by  myself  in  the  Clinical 
Society  s  Transactions,  vol.  xv.  Miss  C,  aged  eighteen, 
was  brought  to  me  in  July,  1881,  with  a  considerable 
swelling  of  the  right  side  of  the  lower  jaw,  some  of  which 
was  evidently  inflammatory,  and  partly  the  result  of  previous 
treatment ;  but  there  was,  I  thought,  sufficient  evidence  of 
expansion  of  the  jaw  to  warrant  the  opinion  that  a  tumour 
was  present,  and  I  therefore  recommended  the  removal  of 
a  portion  of  the  jaw.  Suppuration  was  then  present,  and 
with  the  finger  a  rough  surface  of  apparently  exposed 
bone  could  be  felt,  but  this  I  regarded  as  the  result  of  in- 
flammatory action  excited  by  the  injudicious  irritation  of  a 
periosteal  growth,  since  partial  necrosis  of  a  jaw  involved  by 
•  cartilaginous  or  malignant  growths,  which  have  been  irri- 
tated by  exploratory  measures,  is  in  my  experience  by  no 
means  uncommon.  The  patient  had  the  advantage  of  the 
opinion  of  Sir  James  Paget,  who  was  not  perfectly  satisfied 
as  to  the  existence  of  a  tumour,  and  expressed  a  hope  that 


author's  case  of  odontoma.  219 

the  case  might  prove  to  be  one  of  necrosis.     Under  these 
circumstances  the  operation  was  postponed. 

On  my  return  to  town  in  September,  I  found  the  patient 
improved  in  health  and  the  swelling  diminished  by  the  sub- 
sidence of  the  inflammation,  but  a  considerable  enlargement 
of  the  lower  jaw  still  present,  with  a  sinus  opening  externally. 
From  the  mouth  a  white  mass  was  visible,  which,  appearing 
among  granulations,  looked  like  necrosis,  and  I  agreed  that 
an  attempt  should  be  made  to  remove  this,  although  I  could 
not  think  it  accounted  for  the  expansion  of  the  jaw.  On 
Sept.  8th,  with  the  assistance  of  Dr.  Snow,  the  patient  was 
put  under  chloroform,  and  I  proceeded  to  examine  the  mouth 

Fig.  90.  Fig.  91. 


with  my  finger.  I  soon  found  that  the  white  mass  was  not 
bone  but  tooth,  and  yet  was  unable  to  make  out  its  outline. 
I  was  unable  to  make  any  impression  with  a  chisel  or  gouge, 
but  at  last,  with  an  elevator,  succeeded  in  lifting  out  of  its 
bed  a  mass  of  dental  structures,  forming  the  odontoma  shown 
in  Figs.  90  and  91. 

The  mass  measured  I2  inches  antero-posteriorly,  i  inch 
transversely,  and  li  inches  from  above  downwards.  It 
weighed  315  grains  =  5V  gr.  xv. 

A  section  of  the  odontoma  has  been  made,  and  it  has 
been  submitted  to  Mr.  Charles  Tomes,  who  has  kindly  fur- 
nished the  following  report : 

"  The  whole  surface  of  the  odontoma  is  nodulated  and 
roughened  by  stalactitic  excrescences,  and  there  is  at  no 
point  any  form  recalling  the  character  of  a  tooth  crown. 

"  The  surface  of  a  section  presents  a  complicated  marbled 


220       ODONTOMATA    AND    lEKEGTJLAEITIES    OF    THE    TEETH. 

pattern,  due  to  the  admixture  of  several  dental  tissues,  and 
it  bears  a  general  resemblance  to  that  form  of  dentine  known 
as  '  plici-dentine,'  or  '  labyrintho-dentine.'  On  the  whole  the 
mass  is  of  tolerably  uniform  structure  throughout,  though 
there  is  an  area  of  somewhat  simpler  structure  in  its  upper 
and  central  portion,  from  which  folds  of  dentine  appear  to 
radiate.  So  far  as  it  goes,  this  would  seem  to  point  to 
the  whole  mass  being  the  product  of  a  single  tooth-germ 
rather  than  of  several  fused  together,  a  matter  which  was 
left  in  some  doubt  by  the  absence  of  an  accurate  history 
of  the  case. 

"  The  excrescences  of  the  surface,  as  well  as  the  greater 
part  of  the  interior,  are  made  up  of  folds  of  dentine,  in  which 
dentinal  tubes  are  very  abundant,  and  which  surround  flat- 
tened remnants  of  pulp-chambers  ;  between  and  intimately 
blended  with  this  comparatively  well-formed  dentine,  is  a 
more  coarsely  calcified  material,  containing  numerous  lacunse, 
and  permeated  by  vascular  channels — in  fact,  osteo-dentine. 

"Enamel  is  present  upon  some  of  the  nodules  of  the 
surface,  but  it  does  not  by  any  means  form  a  complete  in- 
vestment; where  present  it  dips  in  folds,  following  the 
convolutions  of  the  dentine,  and  it  is  to  be  met  with  in  the 
very  centre  of  the  mass,  though  not  very  abundantly.  It  is 
nowhere  well  formed,  being  brownish  and  opaque. 

"  This  odontoma  is  the  product  of  the  formative  dentine 
pulp  of  a  tooth  (or  teeth)  which  has,  in  place  of  remaining 
simple,  budded  out  innumerable  processes  on  all  sides,  and 
finally  has  calcified ;  its  enamel  pulp  has  in  parts  followed 
the  complexities  of  its  surface,  and  in  parts  failed  to  do  so,  or, 
at  all  events,  has  failed  to  perpetuate  itself  by  calcification." 

A  case  very  similar  to  the  preceding  was  recorded  by  Dr. 
Arkovy,  of  Buda  Pesth.  The  tenth  case  is  especially  in- 
teresting because  it  occurred  in  the  upper  jaw.  It  occurred 
in  a  man,  aged  twenty-one,  and  is  fully  described  by  Mr. 
Jordan  Lloyd  in  the  Transactions  of  the  Odontological  Society, 
1888.  An  eleventh  case  occuring  in  the  lower  jaw  has 
recently  been  recorded  by  Dr.  Swann  {Lancet,  Dec.  9th, 
1893). 


ANOMALOUS  ODONTOMATA.  221 

All  these  specimens  were  met  witli  in  young  adults,  and 
the  majority  were  extracted  from  the  jaw  by  the  surgeon, 
but  in  Mr.  Harrison's  case  the  mass  came  away  spontane- 
ously ;  and  in  Mr.  Tomes's  and  M.  Forget' s  cases  a  consider- 
able portion  of  the  lower  jaw  being  removed  by  such 
experienced  surgeons  as  Sir  William  Fergusson  and  M. 
Maisonneuve.  In  my  own  case  I  must  confess  that  I  did 
not  appreciate  at  first  the  nature  of  the  tumour,  and  recom- 
mended removal  of  a  portion  of  the  jaw,  and  it  was  only 
during  a  subsequent  operation  undertaken  for  supposed 
necrosis  that  the  true  nature  of  the  case  became  apparent. 

C.  Anomalous  Odontomata. — Under  this  heading,  Bland 
Sutton  places  a  few  remarkable  and  interesting  cases,  and 
I  cannot  do  better  than  describe  them  in  his  own  words  : 

"A  female,  aged  twenty-seven,  applied  for  advice  in  con- 
sequence of  an  attack  of  inflammation  of  the  right  upper 
jaw,  due,  as  she  supposed,  to  the  presence  of  the  roots  of  a 
temporary  molar.  The  temporary  teeth,  so  far  as  was  known, 
presented  nothing  unusual,  and  were  shed  and  replaced  by 
the  permanent  set,  except  that,  on  the  right  side  of  the  upper 
jaw,  the  first  molar,  the  two  bicuspids,  and  canine,  failed  to 
appear.  The  spot  where  these  teeth  should  have  been  became, 
at  the  age  of  twelve,  the  seat  of  hard  painless  enlargement. 
When  the  patient  applied  to  Mr.  Tellander  there  was  a  free 
discharge  of  pus  from  this  spot;  some  stumps  were  removed, 
and  carious  bone  detected.  Subsequent  examination  showed 
that  enclosed  within  this  carious  bone  was  a  cluster  of 
minute  teeth.  There  were  nine  single  teeth,  each  one  per- 
fect in  itself,  having  a  conical  root  with  a  conical  crown 
tipped  with  enamel ;  also  six  masses  built  up  of  adherent 
single  teeth.  The  denticles  presented  the  usual  characters 
of  supernumerary  teeth.  About  a  year  afterwards  a  tooth 
was  found  making  its  appearance  in  the  spot  from  which  the 
host  of  teeth  was  removed. 

"  A  similar  case  has  been  recorded  by  Sir  John  Tomes, 
the  details  of  which  were  communicated  to  him  by  Mr. 
Mathias,  whilst  on  medical  service  in  India.  A  Hindoo, 
aged  twenty,  had  a  large  tumour  which  occupied  the  front 


222       ODONTOMATA   AND    lEEEGULAEITIES    OF   THE   TEETH. 

part  of  the  mouth,  and  pressed  the  upper  lip  against  the 
nose,  thus  preventing  the  closure  of  the  mouth.  After  a 
few  days  of  preliminary  treatment,  a  hard  body  was  detected 
by  a  probe  beneath  the  surface  of  the  tumour ;  this  even- 
tually turned  out  to  be  a  number  of  ill-formed  teeth  united. 
Further  search  was  instituted,  until  at  last  fifteen  masses  of 
supernumerary  teeth  and  bone  were  removed.  The  soft 
parts  rapidly  healed,  the  deformity  disappeared  ;  the  only 
peculiarity  noticeable  was  the  absence  of  the  central  and 
lateral  incisors. 

"A  third  example  of  this  remarkable  condition  has  been 
recorded  by  Mr.  Windle  and  Professor  Humphrey.  The 
case  occurred  in  the  practice  of  Mr.  Sims,  at  the  Dental 
Hospital,  Birmingham.  The  tumour  was  found  in  the 
mouth  of  a  boy  aged  ten  years.  It  was  found  that  neither 
the  deciduous  nor  permanent  right  lateral  incisor  or  canine 
had  erupted.  The  space  thus  unoccupied  was  filled  by  a 
tumour  with  dense  unyielding  walls,  which  occasioned  no 
discomfort.  On  opening  this  cyst,  forty  small  denticles  of 
curious  and  irregular  forms  were  removed  from  the  interior. 
The  largest  possessed  fourteen  cusps.  Many  are  caniniform, 
with  fairly  well-formed  crowns  and  roots,  the  former  being 
covered  with  enamel.  Some  resembled  supernumerary 
teeth,  while  others  consisted  of  several  small  denticles 
cemented  together." 

Symptoms. — The  course  of  the  disease  may  be  conveniently 
divided  into  three  stages.  In  the  first  stage  there  may  be 
no  symptom  or  sign  of  any  abnormal  condition,  but  there  is 
sometimes  a  sense  of  uneasiness  in  the  jaws  or  neuralgic 
pains.  In  the  second  stage  a  tumour  is  found,  generally 
encroaching  upon  the  alveolar  border.  It  increases  in  size 
very  slowly,  and  after  some  time  the  bone  may  be  so  much 
expanded  that  egg-shell  crackling  may  be  obtained.  The 
third  stage  is  marked  by  the  onset  of  inflammatory  symptoms, 
and  finally  an  abscess  forms  which  finds  exit,  if  not  opened 
by  the  surgeon,  by  one  or  more  sinuses.  The  odontoma  may 
become  quite  loose  and  finally  drop  out  (see  p.  2 1 7). 

Diagnosis  and  Treatment. — The  diagnosis  of  these  growths 


IKKEGULAKITIES    OF    THE    TEETH.  223 

is  by  no  means  easy.  In  fact,  in  all  the  cases  hitherto 
described  the  diagnosis  was  not  made  until  an  exploratory 
operation  revealed  the  presence  of  the  odontoma,  or  until  it 
separated  spontaneously  from  the  jaw. 

The  treatment  is  clearly  enough  indicated  if  the  diagnosis 
has  been  made.  Every  effort  should  be  made  to  extract  an 
odontoma  from  the  jaw  without  removing  any  portion  of  the 
jaw  itself.  In  the  case  recorded  by  Mr.  Harrison,  the 
tumour  was  enucleated  spontaneously,  in  seven  cases  it  was 
removed  without  difficulty,  and  in  three  other  cases  its  re- 
moval was  readily  effected  after  the  portion  of  jaw  that 
surrounded  it  had  been  excised. 

Irregtdarities  of  the  Teeth. — Irregular  development  of  the 
teeth  is  of  little  interest  from  a  surgical  point  of  view,  ex- 
cept when,  from  their  abnormal  positions,  they  give  rise  to 
tumours  of  the  jaw.  The  relation  of  cysts  to  undeveloped 
teeth  has  been  discussed  under  the  head  of  "  Dentigerous 
Cysts,"  but  the  solid  growths  directly  connected  with  the 
teeth  also  require  investigation. 

The  irregularities  of  the  teeth  which  are  fully  cut  come 
into  the  province  of  the  dental  surgeon,  and  in  Mr.  Tomes's 
valuable  work  on  Dental  Surgery,  numerous  drawings  are 
given  of  the  abnormal  positions  in  which  various  teeth  have 
appeared.  It  is  the  uncut  teeth,  however,  which  are  of  in- 
terest surgically,  and  these  may  be  divided  into  two  classes. 
In  the  first,  the  tooth  which  has  deviated  from  its  normal 
position  is  still  contained  within  the  alveolus,  where  by  its 
presence  it  may  give  rise  to  a  more  or  less  distinct  tumour. 
Of  this  Fig.  92  gives  an  example  from  the  work  of  Dr. 
Forget,  on  "  Dental  Anomalies,"  for  permission  to  use  which 
I  am  indebted  to  Mr.  E.  T.  Hulme,  the  translator  of  Dr. 
Forget's  papers  in  the  Dental  Review  of  i860.  In  the 
second  class  of  cases  the  misplaced  tooth  is  situated  in  a 
part  of  the  jaw  more  or  less  distant  from  the  alveolus,  and 
of  this  Fig.  93  presents  an  example,  the  canine  tooth  being 
placed  horizontally  in  the  floor  of  the  nasal  fossa,  in  the  in- 
terior of  which  it  formed  a  considerable  projection. 

The  molar  teeth  of  the  upper  jaw,  and  particularly  the 


224       ODONTOMATA  AND    lEREGULAEITIES   OF    THE    TEETH. 

wisdom  teeth,  seem  especially  liable  to  misplacement.     Mr. 
Tomes  {op.  cit.)  gives  numerous  illustrations  of  this  irregu- 


larity, and  in  the  Museum  of  the  College  of  Surgeons  is  a  cast 
of  a  case  in  which  a  wisdom  tooth  projected  through  the  cheek. 

Fig.  93. 


The  wisdom  teeth  of  the  lower  jaw  are  also  prone  to  assume 
an  abnormal  position  in  relation  to  the  coronoid  process,  and 


MISPLACED    TEETH.  225 

in  either  position  a  tumour  may  be  formed  which  may  be 
difficult  of  diagnosis.  Dr.  Forget  {op.  cit.)  quotes  the  case 
of  a  woman  who  had,  on  the  left  side  of  the  hard  palate,  a 
tumour  of  the  form  and  size  of  a  nut,  which  reached  beyond 
the  median  line,  and  extended  from  the  canine  tooth  to  the 
soft  palate.  Blandin,  on  attempting  to  remove  it,  discovered 
it  to  be  caused  by  two  dwarfed  and  abnormally-placed 
molar  teeth,  which  had  penetrated  the  inner  plate  of  the 
alveolus,  and  were  lodged  beneath  the  mucous  membrane  of 
the  palate.  On  the  removal  of  these  the  tumour  subsided. 
A  similar  case  of  tumour  of  the  palate,  due  to  a  molar  tooth, 
is  recorded  in  Tomes'  "  Dental  Surgery." 

The  crown  of  a  temporary  tooth,  of  which  the  fang  has 
been  absorbed,  may  be  so  crowded  in  by  its  permanent 
neighbours  as  to  disappear  within  the  alveolus  and  give  rise 
to  irritation  and  anomalous  symptoms.  I  was  once  con- 
sulted in  a  case  of  this  kind,  when  Mr.  Edgelow  skilfully 
extracted  from  some  depth  the  temporary  crown,  which 
proved  to  contain  a  stopping  ! 

But  the  malposition  of  a  tooth  may  give  rise  to  a  dense 
osseous  tumour  of  the  upper  jaw,  in  which  it  is  impossible  to 
recognise  the  source  of  mischief  until  after  removal  of  the 
tumour.  Of  this  kind  was  a  case  which  occurred  to  Sir 
William  Fergusson,  in  1 8  5  6,  in  a  girl,  aged  thirteen,  in  whom 
for  three  years  there  had  been  growing  a  dense  tumour  of 
the  left  superior  maxilla,  which,  upon  section  after  removal,, 
proved  to  contain  a  tooth  imbedded  in  its  centre. 


CHAPTER  XIV. 

DISEASES   OF    THE    GUMS. — EPULIS. 

Hypertrophy  of  the  Gums  is  by  no  means  a  common  affec- 
tion. Mr.  Salter  has  recorded  (  "  System  of  Surgery,"  ii)  a 
remarkable  case  which  occurred  in  St.  George's  Hospital  in 
1 8  5  9,  in  a  girl,  of  eight  years,  in  whom  there  was  precocious 
development  of  the  teeth,  accompanied  by  hypertrophy  of  the 
gums.  A  large,  pink,  smooth  mass  projected  from  the  mouth, 
slightly  corrugated  or  indistinctly  lobed,  which  consisted 
of  an  expansion  of  the  alveolus,  immense  hypertrophy  of  the 
fibrous  gum,  and  an  exuberant  growth  of  the  papillse  of  the 
mucous  membrane.  Dr.  Gross  has  narrated  a  very  similar 
case  in  his  "  System  of  Surgery"  (1862).  In  April,  1867, 
I  had  the  opportunity  of  seeing  a  case  of  the  kind,  under 
the  care  of  Mr.  Erichsen,  in  University  College  Hospital. 
A  child  of  two  and  a  half  years  had  hypertrophy  of  the 
gums,  which  were  prolonged  in  front  of  and  behind  the  teeth 
so  as  almost  to  conceal  them.  The  disease  affected  only  the 
incisive  portions  of  both  jaws,  and  it  was  remarkable  that 
the  temporary  teeth  had  undergone  hypertrophy  also,  being 
considerably  larger  than  normal.  The  affection  first  showed 
itself  at  the  age  of  seven  months,  when  the  teeth  began  to 
appear,  the  gums  increasing  in  size  and  bleeding  on  the  least 
touch,  Mr.  Erichsen  removed  the  exuberant  growth,  extract- 
ing some  of  the  teeth,  and  freely  cauterized  the  cut  surfaces. 
In  Mr.  Salter's  case  it  was  necessary  to  clip  away  portions 
of  the  alveolus  as  well.  The  excised  portions  in  Mr.  Erichsen's 
case  were  examined  by  the  late  Mr.  A.  Bruce,  who  gave 
the  following  report  upon  them  :  "  On  section  the  mass  was 
found  to  consist  of  a  firm  fibrous  stroma,   containing  much 


HYPERTKOPIIY    OF    THE    GUMS.  227 

glandular  tissue  in  its  interstices,  and  covered  on  its  surface 
by  very  large  and  vascular  papillte.  The  epithelial  layer  was 
of  unusual  thickness,  but  no  abnormal  epithelial  structures 
were  found  in  the  growth,  which  was  an  example  of  true 
hypertrophy."  These  characters  agree  closely  with  those 
.observed  by  Mr.  Salter,  and  it  may  be  remarked  that  though 
in  his  case  the  temporary  teeth  do  not  appear  to  have  been 
hypertrophied,  yet  that  the  permanent  teeth  exposed  in  the 
alveoli  by  the  operation  were  excessively  large,  especially  the 
superior  central  incisors. 

I  am  able  now  to  supplement  my  report  of  Mr.  Erichsen's 
patient,  from  the  Medico-Chirurgical  TransarMons,  vol.  Ivi, 
to  which  the  late  Dr.  John  Murray,  of  the  Middlesex  Hospital, 
contributed  a  paper  "  On  Three  Peculiar  Cases  of  MoUuscum 
Fibrosum  in  Children  of  one  Family."  The  eldest  of  these 
was  Mr.  Erichsen's  patient,  now  seven  years  of  age,  and  she 
presented  peculiarities  of  the  skin,  subcutaneous  connective 
tissue,  periosteum,  and  ends  of  the  fingers  and  toes.  Dr. 
Murray's  description  of  the  oral  cavity  is  as  follows  :  "  The 
appearance  of  the  gums  is  very  remarkable.  They  are  every- 
where greatly  hypertrophied,  and  they  almost  completely 
bury  the  teeth.  They  form  in  parts  numerous  papillomatous 
or  polypoid-looking  growths,  and  in  other  situations  present 
a  peculiar  fungating  appearance,  indeed  this  latter  charac- 
teristic of  the  growth  is  at  once  observed.  The  teeth, 
although  almost  buried  by  the  hypertrophied  gum,  are  still 
in  every  case  visible,  and  are,  in  some  measure,  serviceable 
for  the  purposes  of  mastication.  The  enlargement  of  the 
gums  is  most  marked  at  their  upper  and  free  surface,  where 
they  are  mostly  flattened  out  and  in  parts  hardened  by  the 
pressure  of  the  opposing  gum.  They  present  the  natural 
colour,  and  although  they  are  in  parts  somewhat  soft, 
vascular,  and  spongy-looking,  they  mostly  feel  firm  and 
fibrous  to  the  touch,  the  disease  being  distinctly  limited  to 
the  gums." 

The  patient's  brother,  aged  four,  in  whom  the  growth  was 
first  observed  when  he  was  three  months  old,  aud  her  sister, 
aged  two,  had  a  similar  condition  of  the  gums. 


228 


DISEASES    OF    THE    GUMS. 


It  is  remarkable  that  in  all  the  cases  recorded  there  was  a 
defective  mental  condition,  and  the  hypertrophy  of  the  gums 
had  been  noticed  quite  early  in  life,  and  seemed  to  have  been 
general,  affecting  equally  both  jaws  and  the  whole  extent  of 
the  alveolar  arch.  A  case  of  hypertrophy  of  the  gums 
in  a  woman,  aged  twenty- seven,  was  published  by  Dr. 
Waterman,  of  Boston  {Boston  Medical  and  Surgical  Journal, 
April  8th,  1869)  ;  but  the  most  remarkable  instance  of  the 
disease  on  record,  also  occurring  in  the  adult,  is  given  in  the 
Australian  Medical  Journal  for  August,  1 8  7 1 ,  by  Mr.  Mac- 
Gillivray,  Surgeon  to  the  Bendigo  Hospital,  to  whom   I  am 

Fig.  94. 


indebted  for  photographs  of  the  patient  (Fig.  94).  The 
patient,  a  woman,  aged  twenty-nine,  seemed  to  have  suffered 
from  the  affection  in  both  jaws  at  or  soon  after  birth.  At 
the  age  of  ten,  portions  of  the  gum  were  cut  away  and 
several  teeth  extracted,  and  she  had  herself  in  later  life  cut 
off  portions  of  the  projecting  gum  with  a  razor.  All  these 
operations  gave  rise  to  severe  haemorrhage.  The  enormous 
growth  shown  in  the  drawing  seemed  to  have  originated 
mainly  from  the  palatal  portion  of  the  gums,  the  labial 
surface  being  comparatively  sound.  Mr.  MacGillivray 
removed  the  hypertrophied  gums  and  alveoli  with  perfect 
success. 

In  December,    1878,  I  brought  before  the  Odontological 


HYPERTROPHY    OF    THE    GUMS. 


229 


Society  of  Great  Britain  two  cases  of  hypertrophy  of  the 
gums  which  I  had  treated  successfully  by  operation,  one  in 
a  child  and  the  other  in  an  adult. 

The  first  case  was  that  of  Amy  B.,  aged  four  years  and  a 
half,  who  was  admitted  into  University  College  Hospital, 
May  6th,  1878.  She  is  one  of  five  children  ;  the  other  four 
are  healthy.  Two  years  ago  the  swelling  of  the  gums  began 
by  the  side  of  the  temporary  molars,  which  were  just  coming 
through,  and  from  them  the  swelling  has  spread  right 
round  the  jaw.  At  this  time  she  had  fits  about  once 
a  week  ;  the  fits  have  continued  up  to  the  present  time, 
but  with  longer  intervals.     They  appear  to  be  epileptic. 


Fig.  95. 


Fig.  96. 


The  patient  is  a  very  tractable  child ;  her  general  health 
appears  to  be  good.  The  gums  are  enormously  hypertro- 
phied,  the  teeth  being  entirely  covered,  with  the  exception 
of  the  tips  of  the  crowns,  which  appeared  depressed  in  the 
gums.  The  lower  gums  are  shown  in  Fig.  95,  and  the 
upper  in  Fig.  96,  taken  from  casts.  The  preparation  is  in 
University  College  Museum.  The  hypertrophy  of  the  gums 
is  so  great  that  the  cheeks  are  bulged  out  on  each  side,  and 
the  cavity  of  the  mouth  is  almost  filled  with  them.  The 
teeth  are  irregular  and  slightly  carious.  The  child  is 
always  biting  and  putting  cold  things  in  her  mouth.  She 
can  bite  nothing  hard,  and  has  been  fed  entirely  on  liquid 
or  pulpy  food.      Her  breath  is  very  offensive. 

On  May  9th,  under  chloroform,  I  removed  the  hyper- 
trophied  gums  and  the  alveolar  margin  of  the  lower  jaw  in 
two  pieces.  On  one  side  the  first  permanent  molar  came 
away ;  on  the  other  side  it  was  left,  not  being  quite  erupted. 


230  DISEASES    OF   THE    GUMS. 

Haemorrliage,  which  was  free,  was  stopped  with  the  actual 
cautery. 

On  May  23rd,  under  chloroform,  I  detached  the  hyper- 
trophied  gums  and  alveolar  border  of  the  upper  jaw  in  one 
semi-circular  piece.      Eoots  of  the  permanent  teeth  left. 

On  June  3rd  the  patient  was  discharged  well. 

A  microscopic  examination,  by  Mr,  Charles  Tomes,  showed 
that  the  structure  of  the  growth  closely  resembled  that  of 
the  small  polypi  which  are  sometimes  found  occupying  the 
cavity  of  carious  teeth :  it  was  a  true  hypertrophy  of  the 
gum,  and  chiefly  of  the  fibrous  portion.  It  sprang  from  the 
periosteum  round  the  neck  of    the  teeth,  just  within  the 

Fig.  97. 


margin  of  the  alveoli.  Prom  this  point  a  dense  stroma  of 
interlacing  fibres,  covered  by  a  thin  mucous  and  epithelial 
layer,  grew  up  round  the  tooth,  the  growths  from  opposite 
sides  meeting  over  it  and  coalescing,  so  as  almost  to 
cover  it.  The  attachment  within  the  socket  was  important, 
for  this  explained  how  it  was  that  a  successful  result  could 
not  be  obtained  without  removing  part  of  the  alveolus. 
Unless  this  was  done,  the  base  of  the  growth  was  left 
behind,  and  recurrence  soon  took  place. 

The  second  patient,  Mr.  L.,  aged  twenty-six,  came  under 
my  care  in  June,  1877,  with  hypertrophy  of  the  gum  and 
alveoli  of  the  right  side  of  the  lower  jaw,  extending 
from  the  right  wisdom-tooth  to  the  left  canine.  The 
affection  had  been  noticed  from  early  childhood,  and  gave 
no  pain.     The  condition  of  the  gum  is  seen  in  Fig.  97. 


POLYPUS    OF    THE    GUM.  231 

On  June  I9tli,  the  patient  being  under  chloroform,  I 
removed  the  affected  alveolus  with  Listen's  powerful  cross- 
cutting  forceps.  The  wisdom-tooth  was  left,  but  the  other 
teeth  were  necessarily  sacrificed  up  to  the  left  canine.  The 
ha3morrhage  was  free,  but  was  controlled  with  the  actual 
cautery  freely  applied,  and  the  patient  made  a  good  recovery 
in  a  fortnight.  Mr.  Ibbetson  subsequently  fitted  some 
artificial  teeth  ;  the  patient  is  now  in  much  greater  comfort 
than  before,  and  has  remained  perfectly  well. 

The  growth  is  fibrous  in  structure,  and  is  an  example  of 
pure  hypertrophy.  The  preparation  is  in  University  College 
Museum. 

In  conclusion,  I  would  say  that  nothing  less  than  com- 
plete removal  of  the  affected  alveolus  seems  to  offer  any 
hope  of  alleviating  these  cases.  Mr.  Erichsen  in  1867 
thoroughly  pared  off  the  exuberant  growth  of  the  girl 
Ellen  S.,  but  in  1872  there  was  complete  reproduction  of 
the  disease.  In  the  child  operated  upon  by  me,  the 
condition  of  the  gums  was  such  as  mechanically  to  inter- 
fere with  taking  food,  so  that  there  was  no  hesitation  in 
sacrificing  the  temporary  teeth ;  and  it  may  be  hoped  that 
many  of  the  permanent  teeth  escaped  injury,  and  may  be 
erupted  in  due  course. 

Hypertrophy  of  the  gums  from  the  irritation  of  badly 
fitting  artificial  teeth  is  occasionally  met  with  in  elderly 
patients,  and  in  one  case,  a  lady  whom  I  saw  in  consulta- 
tion with  Mr.  Eichardson,  and  in  whom  the  disease  had 
existed  for  ten  years,  I  found  it  necessary  to  remove  with 
Paquelin's  thermo-cautery  a  considerable  amount  of  tissue 
before  it  became  possible  to  have  fresh  artificial  teeth 
fitted. 

Polypus  of  the  gum  is  the  name  given  to  a  simple  hyper- 
trophy of  the  portion  of  gum  between  two  teeth,  which  is 
ordinarily  dependent  upon  the  irritation  caused  by  those 
organs,  and  may  be  sessile  or  pedunculated.  It  is  often 
connected  with  accumulations  of  tartar  around  the  necks 
of  the  teeth,  and  with  a  generally  unhealthy  condition  of 
the    mouth ;    and    if    cut    away   with    scissors   and   freely 


232  DISEASES    OF    THE    GUMS. 

cauterized  with  the  nitrate  of  silver,  or  better,  Paquelin's 
thermo-cautery,  does  not  recur.  In  one  case  of  large 
polypus  over  a  central  incisor  which  had  been  pivoted,  and 
was  doubtless  a  source  of  irritation,  I  thought  it  safer  to 
remove  a  small  piece  of  alveolus  with  the  bone-forceps  after 
extraction  of  the  tooth,  but  this  is  exceptional.  Mr.  Salter 
describes  a  condylomatous  form  of  disease  of  the  gum,  which 
is  of  a  syphilitic  character. 

Vascular  groiotlis  are  occasionally  met  with  in  connection 
with  the  gum,  and  especially  in  the  region  of  the  incisor 
teeth.  These  bleed  freely  when  rubbed  with  the  tooth- 
brush, and  may,  if  neglected,  grow  to  some  size,  resembling  a 
ngevus  in  their  colour  and  appearance.  Stanley,  in  his  work 
"  On  Diseases  of  the  Bones,"  has  narrated  and  drawn  a  case 
in  which  there  was  a  vascular  growth  in  the  region  usually 
occupied  by  these  growths,  but  in  that  instance  the  tumour 
sprang  from  the  interior  of  the  jaw  and  necessitated  re- 
moval of  a  portion  of  it. 

Mr.  Tomes  has  successfully  treated  the  three  or  four 
examples  of  the  disease  he  has  met  with,  by  the  frequent 
application  of  powdered  tannin.  Mr.  Salter  narrates,  in  the 
"  System  of  Surgery,"  a  case  in  which  hsemorrhage  arose  from 
a  growth  of  the  size  of  a  marble,  which  he  successfully  treated 
by  excision  and  the  application  of  the  actual  cautery,  after 
having  failed  to  effect  a  cure  with  the  ligature.  I  have  also 
met  with  an  example  of  pedunculated  tumour  of  the  gum  in 
a  woman  aged  twenty-five  :  it  bled  when  touched,  and  the 
pedicle  apparently  passed  through  the  alveolus.  I  removed  it 
in  June,  1 869,  by  tearing  through  the  pedicle  with  the  finger- 
nail, and  applied  the  actual  cautery  to  the  spot  from  which 
it  grew,  which  bled  freely.  I  have  twice  met  with  a  very 
vascular  and  hypertrophied  condition  of  the  gums  in  patients 
the  subjects  of  "  port- wine  stain  "  of  the  face.  In  a  young 
married  woman,  of  twenty-four,  the  gums  of  both  jaws  on 
one  side  were  affected,  and  became  more  developed  and 
vascular  during  each  pregnancy,  so  that  she  lost  a  good  deal 
of  blood.  I  twice  removed  the  growth,  arresting  the 
haemorrhage,  which  was  not  severe,  with  the  actual  cautery. 


PAPILLOMA    OF    THE    GUM.  233 

In  the  other  case,  of  a  young  lady  of  seventeen,  the  lip 
and  upper  gum  were  affected,  and  I  was  able  to  bring  about 
a  cure  by  drilUng  with  a  sharp-pointed  cautery. 

Fapilloma  of  the  Gum. — Mr.  Salter  has,  in  the  Guy's 
Hospital  Reports  (1866),  called  attention  to  a  rare  form  of 
disease  in  connection  with  the  jaws,  which  appears  to  consist 
essentially  in  a  hypertrophy  of  the  papilhe  of  the  mucous 
membrane.  The  disease  was  first  noticed  by  Sir  William 
Fergusson,  in  the  lower  jaw  of  an  old  man  of  eighty,  and 
"  looked  like  vegetable  matter,  or  greatly  elongated  papillse," 
as  described  in  some  clinical  observations  on  the  case  by  that 
surgeon  in  the  Lancet,  September  6  th,  1862.  It  was  removed 
by  Sir  William  Fergusson,  and  is  described  by  Mr.  Salter  as 

Fig.  98. 


"  a  curious  white  mass,  consisting  of  coarse  detached  fibres, 
pointed  and  free  at  one  extremity,  and  attached  at  the  other  ; 
in  fact  it  was  a  mass  of  papillje,  many  of  them  nearly  an  inch 
long,  and  similar  in  shape  to  the  '  filiform  '  papillae  of  the 
tongue ;  their  surface  was  shreddy  and  broken  ;  among 
these  elongated  processes  were  a  few  rounded  eminences 
like  '  fungiform '  papilla3,  and  these  had  a  smooth  unbroken 
surface."  The  accompanying  drawing  (Fig.  98),  for  which, 
as  well  as  for  those  that  follow,  I  am  indebted  to  Mr. 
Salter,  represents  a  portion  of  the  tumour  of  the  natural 
size.  Microscopically  the  mass  consisted  almost  entirely  of 
epithelium. 

Mr.  Salter  met  with  a  second  case  in  the  practice  of  Mr. 
Cock,  at  Guy's  Hospital.  It  consisted  in  a  growth  of  the 
size  of  a  split  chestnut  attached  to  the  hard  palate  of  the 
right  side,  and  extended  from  the  edge  to  near  the  median 
line,  as  seen  in  Fig.  99,  and  had  been  growing  about  eight 


234 


EPULIS. 


months.  Mr.  Cock  extirpated  the  growth,  which  consisted 
of  a  hard  mass  of  fibrous  tissue,  surmounted  by  papillae, 
mainly  composed  of  dense    coherent   epithelium  ;  and  met 


Fig.  99. 


with  considerable  difficulty  in  arresting  the  free  haemorrhage 
which  ensued.  Fig.  100  represents  a  section  of  the  growth 
of  the  natural  size.  The  growth  recurred  after  some  time, 
and  took  a  malignant  form,  which  proved  fatal. 

Epulis. — It  has  long  been  the  custom  to  include  certain 
tumours,  under  the  name  of  epulis,  among  diseases  of  the 

Fig.  too. 


gums.  This  is  not  correct,  however,  for  these  growths, 
although  closely  connected  with  the  gums,  do  not  originate 
in  them,  but  in  connection  with  the  alveolar  process  of  the 
jaw^s.  They  really  originate  either  in  the  bone  or  in  the 
periosteum,  and  are  essentially  sarcomatous  in  nature.  In 
many  cases  the  fibrous  element  so  markedly  predominates 
over  the  cellular  element  that  they  are  frequently  regarded 
as  fibromata.  That  they  are  essentially  sarcomata,  however, 
is  shown  by  the  tendency  they  have  to  recur  after  removal, 
unless  the  portion  of  bone  or  periosteum  from  which  they 


EPULIS.  235 

originated  is  removed  also.  In  some  cases  there  is  a 
development  of  bone  to  a  greater  or  lesser  extent  in  the 
interior  of  these  growths,  and  hence  the  term  ossifying  or 
osteo-sarcoma  is  sometimes  applied  to  them.  In  other  cases 
we  may  find  that  the  tumour  presents  the  naked-eye  and 
microscopical  characters  of  a  myeloid  sarcoma.  It  is  very 
probable  that  the  growths  may  originate  in  one  of  two 
situations,  either  in  the  periosteum  when  we  get  the  ordi- 
nary fibrous  or  the  osteo- sarcomatous  epulis,  or  in  the  bone 
itself  when  we  get  the  myeloid  epulis.  Although  it  is 
important  to  recognise  the  sarcomatous  nature  of  epulis,  yet 
we  must  remember  that  the  growth  differs,  clinically,  from 

Fig.  ioi: 


ordinary  sarcomata  of  bone.  Epulides  possess  a  very  low 
form  of  malignancy,  so  that  if  the  part  of  the  bone  to  which 
they  are  attached  is  removed  with  the  growth,  there  is  no 
tendency  to  recurrence. 

The  accompanying  drawing  (Fig.  loi),  for  which  I  am 
indebted  to  Mr.  Jonathan  Hutchinson,  gives  a  good  idea  of 
the  naked-eye  appearance  presented  by  a  section  of  an  epulis 
of  large  size.  This  form  of  the  disease  is  closely  connected 
with  the  fibrous  gum,  and  also  with  the  periosteum  of  the 
alveolus,  and  very  generally  small  spicula  of  bone  are  x^i^o- 
longed  into  it  from  the  maxilla  ;  the  mucous  membrane  of 
the  gum  is  stretched  over  the  growth.  Occasionally  a 
develojpment  of  true  bone  takes  place  in  distant  parts  of  the 
growth,  as  in  the  specimen  drawn  above  ;  so  also  in  a  large 
epulis  which  I  removed  from  the  upper  jaw  of  a  young 
woman,  and  which  accompanied  this  essay  (College  of  Sur- 


236 


EPULIS. 


geons'  Museum),  a  nodule  of  bone  of  considerable  size  is 
developed  near  the  surface  of  the  growth  and  quite  uncon- 
nected with  the  alveolus.  Mr.  Caesar  Hawkins  mentions 
{Medical  Gazette,  1846)  a  similar  occurrence  in  a  case  where 
the  epulis  was  pedunculated. 

The  myeloid,  or  softer  and  more  vascular  form  of  epulis, 
is  composed  of  a  small  quantity  of  fibrous  tissue,  holding  in 
its  meshes  the  true  poly-nucleated  myeloid  cells,  or  "  myelo- 
plaxies."  The  drawing  from  which  Fig.  102  was  taken  (also 
given  me  by  Mr.  Hutchinson)  showed  the  vascular  appear- 
ance of  such  a  tumour  on  section,  the  one  in  question  having 
formed  a  large  overhanging  mass  upon  the  lower  jaw,  which 
was  excised  by  Mr.  Curling  in  1864. 


Fig.  102. 


Fig.  103. 


In  Eig.  103  is  seen  a  section  of  a  well-marked  myeloid 
epulis,  removed  by  Mr.  Wilkes,  of  Salisbury  (College  of 
Surgeons'  Museum) .  The  tumour  consists  of  a  semi-globular 
firm  elastic  mass  attached  by  its  base  to  the  margin  of  the 
alveolus,  from  within  which  it  springs.  Its  surface  is 
smooth  and  uniform,  and  of  a  dark  grey  colour,  mottled 
with  purplish  spots.  On  section  it  can  be  traced  into  the 
bone,  the  cut  surface  being  for  the  most  part  of  a  greyish 
yellow,  with  patches  of  pink  and  purple.  The  microscopical 
examination  shows  interspersed  among  the  fine  fibrous  tissue 
some  large  irregular  disc-like  cells,  containing  numerous 
bead-like  nuclei,  and  the  growth  may  therefore  be  considered 
similar  to  that  described  by  Otto  Weber  as  "  giant-celled 
sarcoma." 

This  form  of  epulis  is  more  commonly  connected  with  the 
interior  of  the  alveolus  than  the  fibrous  variety ;  and  this 
fact  may  possibly  account  for  its  being  more  closely  allied 


EPULIS.  237 

to  the  endosteal  than  the  periosteal  structures.  In  fact, 
many  of  the  so-called  myeloid  epulides  are  really  only  out- 
growths from  myeloid  tumours  of  the  interior  of  the  jaw,  and 
hence  their  great  tendency  to  recur  if  insufficiently  removed. 
It  is  this  form  which,  when  irritated  and  ulcerated,  presents 
an  appearance  somewhat  resembling  malignant  disease.  Ir- 
regular nodules  of  bone  may  be  scattered  through  the  myeloid 
as  through  the  fibrous  variety,  and  the  occasional  occurrence 
of  a  cyst  in  connection  with  an  epulis  must  not  be  overlooked. 
I  have  recently  had  a  case  of  the  kind  under  my  care,  in 
which  the  presence  of  a  cyst  by  the  side  of  a  fibrous  epulis 
gave  a  formidable  appearance  to  a  simple  disease. 

A  form  of  epulis  possessing  some  of  the  characters  of 
epithelioma  is  occasionally  met  with.  A  specimen  which 
was  sent  to  me  in  a  perfectly  fresh  state  by  Mr.  Hutchinson, 
who  had  removed  it  from  the  lower  jaw  of  a  lady,  aged  fifty- 
five,  where  it  had  been  growing  a  year,  was  examined  by 
the  late  Mr.  Bruce  with  the  following  report :  "  The  surface 
of  the  tumour  is  covered  with  healthy  mucous  membrane. 
The  interior  of  the  tumour  is  whiter,  firmer,  and  more 
compact  than  the  surface ;  but  there  is  no  line  of  demarca- 
tion between  the  tumour  and  its  mucous  covering.  The 
structure  of  the  growth  is  distinctly  glandular,  very  much 
resembling  some  forms  of  compact  adenoid  tumour  of 
the  breast.  At  the  point  of  attachment  of  the  tumour 
to  the  parts  beneath,  a  remarkable  transformation  of  the 
glandular  into  the  epitheliomatous  structure  is  seen. 
In  one  part  of  the  section  may  be  seen  the  cut  ends  of 
gland  tubules,  whilst  in  their  immediate  neighbourhood  are 
most  distinct  nests  of  true  epithelioma,  consisting  evidently 
of  concentrically  arranged  cells  compressed  from  the  centre 
outwards." 

Mr.  Eve  has  also  placed  in  the  Museum  of  the  College 
of  Surgeons  an  epulis  which  microscopically  had  the 
character  of  an  epithelioma,  but  contained  no  '  cell- 
nests.' 

It  is  probable  that  these  epitheliomatous  growths  origi- 
nated in  the  rudimentary  epithelial  structures  discovered  by 


238  EPULIS. 

Malassez  and  described  in  the  chapter  on  Cysts  of  the  Jaw 
(see  p.  172). 

Epulis  appears  to  be  generally  connected  with  the  presence 
of  teeth,  and  in  some  cases  to  depend  upon  the  irritation 
caused  by  them ;  but  I  have  once  seen  a  small  fibrous  epulis 
in  a  newly  born  child.  The  simplest  form  is  often  found 
growing  between  two  perfectly  sound  teeth,  which  become 
widely  separated,  as  seen  in  the  illustration  (Fig.  104),  taken 
from  a  patient  of  Dr.  Langston,  in  whom  I  was  obliged  to 
sacrifice  the  central  incisors  in  order  to  remove  the  growth ; 
in  some  instances  the  pedicle  attaching  the  growth  may  be 
so  slender  as  to  be  broken  by  the  tongue  of  the  patient  or 
the  finger  of  the  surgeon,  of  which  Sir  William  Fergusson 
gives  examples.     The  teeth  may  be  unsound  and  broken, 

Fig.  104. 


and  in  these  cases  the  growth  often  completely  envelops  the 
stumps  and  hides  them  from  view,  or  in  the  progress  of  the 
growth  a  fang  of  a  tooth  may  be  pushed  forward,  and 
be  eventually  found  imbedded  in  its  centre,  as  narrated  by 
Mr.  Tom£s. 

The  two  jaws  appear  to  be  equally  liable  to  the  disease, 
but  its  position  and  extent  are  subject  to  great  variation.  In 
the  simplest  form  it  may  be  connected  with  only  the  outer 
plate  of  the  alveolus,  or  may  be  attached  at  a  slight  depth 
within  the  socket  of  a  tooth.  In  other  instances  it  is 
attached  solely  to  the  posterior  plate  of  the  alveolus,  and 
protrudes  the  teeth  or  appears  behind  them ;  in  the  more 
severe  cases  of  myeloid  disease  it  involves  the  whole  thick- 
ness of  the  jaw,  and  either  envelops  or  carries  the  teeth 
before  it.  Of  this  a  case  of  Dr.  Fleming's  (Dublin  Quarterly 
Journal,   February,    1866)    gives    a   good   example   at    an 


EPULIS.  239 

unusually  early  age,  the  boy  being  between  five  and  six,  and 
the  disease  occurring  between  the  first  and  second  temporary 
molar  teeth  of  the  lower  jaw,  both  of  which  were  dis- 
placed and  imbedded  in  the  morbid  growth. 

When  the  tumour  attains  a  moderate  size,  if  it  be  on  the 
upper  surface  of  the  alveolus  it  is  apt  to  be  pressed  upon  by 
the  teeth  of  the  opposite  jaw,  and  this  not  only  gives  rise  to 
pain  and  inconvenience,  but  causes  also  indentations  and 
possibly  ulcerations  on  its  surface.  Fig.  105  is  reduced  from 
a  cast  of  the  upper  jaw  of  a  young  woman,  a  patient  of  Mr. 
Warn,  of  the  Highgate  Eoad,  from  whom  I  removed  a  large 
epulis  containing  bone,  which  has  been  already  referred  to. 

Fia.  105. 


The  patient  was  twenty-seven  years  of  age,  and  the  growth 
had  existed  two  years,  and  it  will  be  seen  that  the  surface  is 
grooved  and  indented  by  the  teeth  of  the  lower  jaw.  In  this 
case  the  fangs  of  the  first  and  second  molar  teeth  were  found 
in  the  alveolus  beneath  the  epulis. 

A  fibrous  epulis,  if  allowed  to  grow  to  a  large  size,  will 
produce  external  deformity  of  the  face,  and  although  attached 
to  the  upper  jaw  may  hang  down  so  as  to  simulate  disease 
of  the  lower  jaw.  This  was  well  seen  in  a  woman,  aged 
twenty-seven,  who  had  an  epulis  of  the  upper  jaw  of  seven 
years'  growth,  which  hung  down  to  the  level  of  the  angle  of 
the  jaw,  and  who  was  under  the  care  of  Mr.  Erichseu,  by 
whom  the  tumour  was  removed  in  1861,  with  perfect 
success.  Perhaps  the  most  remarkable  case  of  epuloid  growth 
on  record,   however,  is  Mr.    Listen's  well-known    patient. 


240 


EPULIS. 


Mary  Griffiths,  from  whom,  in  October,  1836,  he  removed 
the  growth  shown  in  the  accompanying  drawing  (Fig.  106). 
The  case  is  reported  at  length  in  the  Lancet  of  Nov.  5  th, 
1836,  and  is  also  referred  to  in  Mr.  Liston's  "Practical 
Surgery,"  from  which  both  the  illustrations  are  taken.  The 
following  summary  of  it  is  from  a  note  to  Mr.  Liston's  paper 
on  Tumours  of  the  Jaw,  in  the  MecUco-CMrurgical  Transac- 
tioiis,  vol.  XX. 

Fig.  106. 


"  The  patient  had  laboured  under  the  disease  for  eight 
years,  and  had  been  subjected  to  a  partial  removal  of  the 
growth  when  of  inconsiderable  size.  The  tumour  was  of  the 
same  nature  as  those  of  the  third  and  fourth  cases  related 
in  the  paper  {i.e.,  fibroid),  as  regards  its  disposition,  form, 
and  intimate  structure.  It  differed  somewhat,  however,  in 
outward  appearance,  in  consequence  of  its  exposed  situation. 
The  growth  sprang  originally  from  the  gums  and  sockets  of 
the  incisors  and  canine  tooth  of  the  left  side ;  at  an  early 
period  it  protruded  from  the  mouth,  unconfined  and  unin- 
fluenced by  the  pressure  of  the  lips  or  cheek.     It  had  assumed 


EPULIS. 


241 


a  most  formidable  size  and  appearance,  concealed  the  palate 
and  pharynx,  and  gave  rise  to  great  inconvenience  and 
continued  suffering.  The  surface  had  been  broken  by  ulcera- 
tion, but  upon  a  close  inspection  of  the  projecting  part  and 
of  that  cavered  by  the  cheek,  it  was  found  to  possess  a  firm 
consistence,  and  to  present  the  same  peculiar  botryoidal 
arrangement  of  its  parts  as  the  others  of  a  simple  and 
benign  nature.     The  operation  proved  perfectly  successful." 

Fig.  107. 


Fig.  107  shows  the  after-condition  of  the  patient,  the  scars 
in  the  upper  lip  being  the  result  of  the  previous  unsuccessful 
attempt  to  remove  the  disease.  The  preparation  is  in  the 
Museum  of  the  College  of  Surgeons. 

A  case,  very  similar  in  many  respects  to  the  preceding 
one,  was  successfully  operated  upon  in  1869  by  Professor 
Kinloch,  of  Charlestown.  The  patient  was  a  negress,  aged 
twenty-five,  and  presented  much  the  appearance  shown  in 
Eig.  106,  the  mouth  being  enormously  distended  by  a  pro- 
truding growth,  which  appeared  to  have  originated  in  the 

Q 


242  EPULIS. 

alveolus,  but  to  have  involved  the  superior  maxilla.  Dr. 
Kinloch  removed  the  mass,  which  weighed  nearly  two 
pounds,  and  the  patient  made  a  good  recovery. 

Treatment  of  Epulis. — No  treatment  less  radical  than 
removal  of  the  growth  is  of  the  slightest  advantage.  In  the 
case  of  a  small  epulis  growing  between,  or  close  to,  the  incisor 
teeth,  after  removal  with  the  knife  an  attempt  may  be  made 
to  check  the  reproduction  of  the  disease  by  the  application 
of  nitrate  of  silver  or  a  line  cautery,  but  usually  without 
success.  An  epulis  attached  to  the  outer  surface  of  the 
alveolus  only  may  be  cut  away  or  detached  by  the  nail,  and 
the  surface  be  thoroughly  cauterised,  but,  as  has  been  already 
said,  the  growth  is  connected  with  the  periosteum  and  will 
often  be  reproduced  from  it.  It  is  essential  then  to  remove 
the  periosteum,  and  this  may  be  done  with  a  chisel  or 
gouge,  by  which  a  small  scale  of  the  alveolus  with  its  cover- 
ing can  be  cut  away.  Those  who  object  to  such  a  pro- 
ceeding may  produce  the  same  result  by  the  application  of 
such  a  powerful  caustic — either  potassa  fusa,  nitric  acid,  or 
the  hot  iron — as  shall  destroy  the  surface  of  the  bone  and 
cause  its  exfoliation,  but  with  some  tediousness  and  incon- 
venience to  the  patient. 

In  some  cases  the  epulis  originates  in  the  alveolo-dental 
periosteum.  When  such  is  the  case,  the  tooth  should  be 
extracted  and  the  epulis  will  come  away  with  it.  In  cases 
of  large  fibrous  epulis  a  tooth  must  be  extracted  on  each 
side,  and  the  whole  thickness  of  the  alveolus  cut  away  with 
bone-forceps,  of  which  Listen's  cross-cutting  forceps,  shown 
in  Figs.  1 08  and  109,  are  very  serviceable;  the  straight 
ones  for  the  incisor,  and  the  angular  for  the  molar  region. 
The  same  radical  treatment  will  be  advisable  when  the 
disease  springs  from  the  posterior  plate,  and  in  all  these 
cases  I  make  an  invariable  practice  of  applying  the  actual 
cautery  to  the  surface  of  bone  exposed  by  the  operation, 
which  has  the  advantage  of  stopping  haemorrhage,  and  of 
causing  the  exfoliation  of  any  diseased  portions  of  bone 
which  may  have  been  left.  In  all  operations  of  the  kind, 
any  roots  of  decayed  teeth  which  may  be  discovered  at  the 


TREATMENT    OF   EPULIS. 


243 


time  of  the  operation  should  be  extracted  with  the  forceps 
or  elevator,  and  the  surface  of  the  bone  rendered  as  smooth 
as  may  be. 

When  the  epulis  is  connected  with  the  lining  membrane 
of  the  socket  of  a  tooth,  and  dips  down  into  the  interior  of 
the  jaw,  it  is  probably  myeloid,  and  no  superficial  operation 
can  effect  a  cure,  since  it  is  in  this  class  of  cases  that 
repeated  reproductions  are  met  with.  The  neighbouring 
teeth,  although  sound,  must  generally  be  sacrificed,  and  the 
alveolus    thoroughly   cleared  out  with   the   gouge,  so   that 


Fig.  ioS. 


Fig.  109. 


nothing  but  the  shell  of  compact  bone  is  left.  The 
haemorrhage  is  usually  free,  and  is  best  controlled  by 
stuffing  the  cavity  with  lint.  In  1875  I  saw  a  young 
gentleman,  aged  nineteen,  with  Mr.  Braine,  in  whose  lower 
jaw  there  was  a  small  myeloid  growth,  which  I  freely 
removed.  Eecurrence  took  place,  however,  and  I  operated 
a  second  time,  clearing  out  the  alveolus  very  thoroughly^ 
but  fortunately  being  able  to  preserve  the  teeth,  and  the 
patient  is  now  quite  well,  eighteen  years  afterwards. 

When  the  epulis  is  very  extensive,  it  may  be  conveniently 
removed,  with  the  alveolus  to  which  it  is  attached,  by 
making  a  vertical  incision  with  a  small  saw  at  each 
extremity  of  the  disease,  and  then  connecting  the  cuts  by  a 


244 


EPULIS. 


horizontal  one  with  cross-cutting  bone  forceps.  Under  no 
circumstances,  except  when  the  growth  is  of  a  malignant 
character,  can  it  be  necessary,  I  believe,  to  cut  through  the 
whole  thickness  of  the  lower  jaw,  since  it  has  been  shown 
repeatedly  that  common  epulis  never  involves  the  base  of 
the  bone,  and  the  contour  of  the  face  depends  so  much  upon 
its  preservation,  that  it  should  not  be  interfered  with. 

When  the  growth  is  of  large  size  and  situated  at  the  side 
of  the  mouth,  some  difficulty  may  be  experienced  in  extir- 
pating it,  but  with  properly  made  angular  and  semi-circular 


Fig.  no. 


Fig.  Ill, . 


bone- forceps  (Figs,  no  and  in)  this  may  generally  be 
overcome.  It  may  be  necessary,  however,  to  incise  the  face, 
and  if  so,  the  suggestion  and  practice  of  Sir  William  Fergus- 
son  ("Lectures  on  Progress  of  Surgery,"  p.  239)  cannot  be 
too  strictly  followed — viz.,  to  restrict  the  incision  to  the 
middle  line  of  the  lip,  which  will  ordinarily  give  abundance 
of  room  ;  or,  if  not,  to  carry  it  into  the  nostril  of  the  affected 
side,  by  the  stretching  of  which  so  much  additional  room 
will  be  gained  as  to  render  any  incision  at  the  angle  of  the 
mouth  perfectly  unnecessary.  When  this  limited  incision 
is  adhered  to,  the  scar  is  so  slight  as  to  be  imperceptible 
except  upon  the  closest  investigation.  In  instances  of  such 
enormous  growths  as  in  the  case  of  Mary  Anne  Griffiths, 
more  extensive  incisions,  resembling   those   for  excision  of 


EPITHELIOMA    OF   THE    GUM.  245 

the  jaw,  would  be  required  ;  but  such  cases  are  now-a-days 
few  and  far  between.  Mr.  Liston  considered  it  necessary 
to  remove  the  left  and  a  portion  of  the  right  maxilla,  but 
subsequent  examination  showed  that  these  bones,  though 
overlain  by  the  disease,  were  not  implicated  in  it  except  at 
their  alveolar  borders. 

Upithelioma. — Some  authors  are  inclined  to  include  epi- 
theliomata  among  the  epulides,  but  any  outgrowth  or 
tumour  in  the  early  stage  of  the  disease  is  quite  exceptional, 
and  therefore  an  epithelioma  can  scarcely  be  called  an  epulis. 
On  pathological  grounds,  moreover,  it  would  be  absurd  to 
classify  epithelioma  and  epulis  together.  The  former  is 
a  primary  disease  of  the  gums,  commencing  in  the  epithelium ; 
the  latter  is  a  primary  disease  of  the  alveolar  process,  com- 
mencing in  some  part  of  the  bone.  A  ragged  ulceration  of 
the  gum,  supposed  to  be  dependent  upon  some  tooth,  and 
probably  the  direct  result  of  long-continued  irritation,  is 
noticed,  but  the  pain  is  not  marked  and  the  inconvenience  is 
slight.  Careful  observation  will  soon  detect  a  tendency  of  the 
ulceration  to  spread  both  towards  the  tongue  and  the  cheek, 
and  by  this  time,  probably,  induration  of  the  base  of  the 
ulcer  may  be  detected  where  it  touches  the  softer  tissues. 
The  importance  of  prompt  and  thorough  interference  cannot 
be  too  strongly  impressed  upon  members  of  the  dental  pro- 
fession, by  whom  cases  of  epithelioma  are  more  generally 
seen  in  the  early  stage.  In  a  recent  case  of  ulceration  of 
the  gum,  simple  treatment  may  fairly  be  tried  for  a  week  or 
ten  days,  but  if  the  ulcer  still  remains  unhealed,  and  more 
particularly  if  it  is  increasing,  surgical  aid  should  at  once 
be  summoned.  The  frequent  application  of  the  solid  nitrate 
of  silver  to  an  ulcer  which  fails  to  heal  readily,  is  worse 
than  useless.  The  treatment  of  an  epitheliomatous  ulcer 
consists  in  thoroughly  destroying  it,  with  the  tissue  around 
for  some  distance.  In  slight  or  doubtful  cases  thorough 
application  of  the  strongest  nitric  acid,  the  acid  nitrate  of 
mercury,  or  better,  the  actual  cautery,  may  be  sufficient  to 
ensure  a  healthy  cicatrization ;  but  even  then  the  part  will 
require  careful  watching,  in  order  that  any  fresh  development 


246  EPULIS. 

may  be  promptly  attacked.  Unfortunately  the  disease  has, 
in  the  majority  of  cases,  already  invaded  the  alveolus,  as  is 
shown  by  the  swelling  of  the  gum  and  the  loosening  of  the 
teeth ;  and,  when  this  is  the  case,  free  removal  of  the  bone 
must  be  undertaken.  A  vertical  cut  with  a  narrow  saw 
being  made  through  the  whole  depth  of  the  alveolus  well 
beyond  the  disease,  the  cross-cutting  bone-forceps  may  be 
used,  or  the  saw  applied  horizontally  to  remove  the  diseased 
portion,  as  is  shown  in  Fig.  112,  taken  from  Fergusson. 
The  danger,  of  course  is  that  the  disease  may  have  pene- 
trated more  deeply  than  appears  into  the  bone,  so  that 
recurrence  is  apt  to  take  place  rapidly  from  the  epithelio- 
matous  elements  left  behind.     Should  this  occur,  there  must 

Fig.  112. 


be  no  hesitation  in  removing  the  whole  thickness  of  the 
bone,  and  in  the  incisor  region  the  residting  inconvenience 
is  much  less  than  might  be  anticipated,  the  muscles  attached 
to  the  two  halves  of  the  jaw  forcing  them  together,  so  that 
tough  fibrous,  if  not  bony,  union  takes  place  in  the  position 
of  the  original  symphysis. 

Some  years  ago  a  man  was  sent  to  me  by  Mr.  Harding 
with  an  undoubtedly  epitheliomatous  growth  springing  from 
the  gum  in  the  incisor  region.  This  I  removed  by  sawing 
the  lower  jaw  horizontally  below  the  level  of  the  alveolus, 
but,  the  section  not  proving  quite  healthy  in  appearance,  I 
thought  it  advisable  to  take  away  the  whole  thickness  of 
the  jaw  in  this  region.  The  patient  made  a  good  recovery, 
with  firm  union  between  the  two  segments  of  the  jaw,  and 
I  have  not  heard  of  any  further  recurrence. 

An  equally  satisfactory  case  has  come  under  my  frequent 


EPITHELIOMA    OF    THE    GUM.  247 

observation  during  the  last  twelve  years,  in  the  person  of  a 
retired  officer  of  the  army,  who  in  1879,  after  wearing 
a  lower  dental  plate  for  some  years,  developed  epithelioma 
of  the  gums  and  cheeks.  Professor  Bowen  Partridge,  of 
Calcutta,  removed  the  left  half  of  the  body  of  the  jaw  in 
December,  1879,  and,  recurrence  taking  place  at  the  chin. 
Dr.  McLeod  removed  the  right  in  March,  1880,  with  the 
sub-maxillary  glands  of  both  sides,  I  first  saw  this  gentle- 
man in  July,  I  88  I,  when  the  central  portion  of  the  jaw  was 
of  course  gone,  and  there  was  a  space  of  i  inch  between  the 
halves  of  the  bone.  The  tissues  around  were  contracted, 
but  perfectly  healthy,  and  his  only  complaint  was  a  sense 
of  tightness  and  want  of  saliva.  During  the  next  two  years 
the  portions  of  jaw  became  approximated,  and  the  growth  of 
a  beard  hides  the  want  of  chin ;  I  have  recently  seen  this 
patient,  and,  as  nearly  fourteen  years  have  elapsed  since  the 
operation,  the  cure  may  now  be  considered  permanent. 

In  the  Museum  of  the  College  of  Surgeons  are  two 
specimens  of  epithelioma  of  the  alveolus  in  which  a  less 
satisfactory  result  followed.  The  patient  was  a  gentleman, 
aged  fifty-four  when  he  was  sent  to  me  by  Mr.  Weiss,  with 
a  well-marked  epitheliomatous  condition  of  the  right  lower 
alveolus,  between  the  first  molar  and  the  canine  teeth, 
which  had  been  noticed  six  months.  In  addition,  a  well- 
marked  ichthyotic  condition  of  the  mucous  membrane  of  the 
floor  of  the  mouth  extended  along  the  inner  side  of  the  body 
of  the  jaw  and  beneath  the  tongue.  In  September,  1880, 
I  burnt  away  the  whole  of  the  affected  mucous  membrane 
with  Paquelin's  cautery,  and  having  deeply  notched  the 
alveolus  with  the  saw,  I  clipped  out  the  affected  portion 
with  bone-forceps.  Two  months  later  the  disease  began  to 
show  itself  on  the  inner  side  of  the  jaw,  and  in  April,  1881, 
I  removed  the  part  affected  very  freely,  cutting  away  the 
whole  thickness  of  the  bone  from  the  second  molar  of  the 
right  to  the  second  incisor  of  the  left  side,  with  the  adjacent 
lymphatic  gland,  the  section  of  bone  being  apparently  healthy. 
Eecurrence  took  place,  however,  shortly,  and  in  November  I 
removed  a  further  portion  of  the  left  side  of  the  lower  jaw 


248  ,  EPULIS. 

up  to  the  first  molar  tooth  (College  of  Surgeons'  Museum). 
Notwithstanding  this  complete  removal  of  the  disease,  it 
returned  in  the  soft  parts  beneath  the  tongue,  large  masses 
protruded  into  the  mouth,  and  the  patient  sank  in  November, 
1882. 

Both  in  this  and  other  similar  cases  I  have  been  disap- 
pointed with  the  operation  of  removing  solely  the  alveolus, 
and  am  inclined  to  adopt  more  radical  measures  at  first  in 
future,  being  encouraged  to  do  so  both  by  the  great  success 
of  the  officer's  case  already  mentioned,  and  by  a  case  occur- 
ring in  University  College  Hospital. 

This  case  was  one  of  a  man,  aged  fifty-two,  who  was 
under  my  care  in  1875  with  extensive  epithelioma  of  the 
front  of  the  tongue,  which  was  firmly  fixed  by  its  tip  to 
the  lower  jaw,  with  great  enlargement  of  the  submaxillary 
glands  and  infiltration  of  the  submaxillary  tissues.  He 
suffered  acutely  from  occipital  pain,  which  it  is  difiicult 
to  explain,  and  was  willing  to  submit  to  any  operation 
for  relief.  I  divided  the  jaw  on  each  side  one  inch 
and  a  half  from  the  symphysis,  and  then  removed  the 
front  of  the  tongue,  the  centre  of  the  jaw,  and  all  the 
sub-lingual  structures,  with  the  galvanic  4craseur  (University 
College  Museum).  The  patient  made  a  rapid  recovery,  the 
two  portions  of  jaw  fell  together,  and  are  now  united  at  an 
angle  by  tough  fibrous  tissue,  and  the  man,  who  was  alive 
and  well  in  1893,  has  covered  the  deformity  by  growing  a 
beard. 

In  January,  1879,  I  performed  nearly  as  extensive  an 
operation  on  a  man,  aged  sixty-eight,  removing  the  lower 
jaw  from  the  right  incisors  to  the  left  angle,  for  extensive 
epithelioma  of  the  jaw  and  floor  of  the  mouth,  the  patient 
making  a  good  recovery  and  being  in  perfect  health  two 
years  later,  but  dying  with  recurrence  of  the  disease 
eventually  {Lancet,  November  20th,  1880). 


CHAPTEE    XV. 

TUMOUKS   OF  THE   PALATE. 

Tumours  of  the  palate  had  not  attracted  much  notice  in  this 
country  until  Mr.  Stephen  Paget  published  a  very  interesting 
and  valuable  paper  in  the  ^S'^.  Bartholomeiv  s  Hospital  Beports, 
1886.  We  cannot  do  better  than  quote  his  remarks  intro- 
ducing the  paper  :  "  Tumours  of  the  palate  have  not  at- 
tracted much  notice,  yet  they  form  a  group  of  great  interest. 
They  are  of  many  kinds — cystic  and  solid,  innocent  and 
malignant.  In  the  small  space  of  the  palate  almost  every 
sort  and  kind  of  tumour  have  been  observed  :  cysts,  nsevi, 
papillary  growths  ;  tumours  of  bone  and  of  cartilage  ;  gland- 
ular, sarcomatous  and  cancerous  growths.  As  regards  their 
microscopic  structure,  there  is  still  much  to  be  made  out ; 
and,  as  regards  their  pathology,  it  is  worth  while  to  observe 
how  closely  some  of  them  resemble  the  tumours  of  the 
parotid  region.  Thus,  their  structure  is  uncertain  and  com- 
plex ;  they  may  contain  cartilage,  bone,  striped  muscle,  and 
glandular  and  embryonic  tissues ;  the  cells  may  be  embryonic, 
myxomatous,  sarcomatous,  or  epithelial.  This  same  complex 
and  heterogeneous  structure  is  found  in  tumours  of  the  parotid 
region.  Again,  in  their  slow  yet  uncertain  rate  of  growth, 
and  in  their  general  behaviour,  some  tumours  of  the  palate 
are  very  like  the  tumours  of  the  parotid  region.  If,  there- 
fore, Cohnheim's  theory  holds  good  of  tumours  of  the  parotid 
region,  as  Mr.  Jacobson  has  shown  in  his  admirable  paper 
on  the  '  Enchondromata  of  the  Salivary  G-lands,'  this  same 
theory  may  also  be  applicable  to  tumours  of  the  palate. 
These,  too,  may  be  of  embryonic  origin,  may  grow  from 
particles  of  embryonic  tissue  which  have  long  lain  dormant. 


250  TUMOUES    OF    THE    PALATE. 

and  this  theory  of  the  origin  of  certain  tumours  of  the 
palate  receives  some  support  from  the  fact,  that  there  is  no 
part  of  the  body  which  suffers  more  than  the  palate  from 
arrest  and  perversion  of  development.  It  is  formed  by  a 
very  comphcated  folding-in  of  foetal  structures ;  and  it  is 
just  in  such  a  region  as  this  that  a  superabundant  formation 
of  embryonic  tissue  would  naturally  take  place.  In  one  case, 
indeed,  tumour  of  the  palate  was  associated  with  perverted 
development  of  the  palate  and  mouth.  Again,  the  occurrence 
of  true  congenital  dermoid  tumours  and  vascular  erectile 
growths  in  the  palate  may  be  taken  as  evidence  that  some 
tumours  of  the  palate  have  an  embryonic  origin." 

Cysts  of  the  Palate. — A  few  cases  of  dermoid  cyst  have 
been  described.  They  are  usually  noticed  soon  after  birth. 
In  the  majority  of  cases  the  child  has  been  born  with  the 
tumour,  and  in  some  of  them  the  tumour  has  been  so  large 
at  birth  that  the  life  of  the  child  was  in  jeopardy  from 
asphyxia.  A  typical  case  is  described  by  Dr.  Hale  White 
in  the  Pathological  Society's  Transactions,  1 8  8 1 . 

Simple  serous  cyst  of  the  palate  is  very  rare,  and  Stephen 
Paget,  after  a  prolonged  search,  was  able  to  find  only  one  case 
recorded  in  surgical  literature.  Dentigerous  cysts  are 
occasionally  found  in  the  hard  palate.  They  form  dense 
projections  from  the  bony  palate,  covered  by  the  healthy 
mucous  membrane. 

Angiomata. — These  may  be  congenital  or  acquired.  The 
latter  frequently  seem  to  form  in  the  neighbourhood  of  a 
carious  tooth.  They  are  cavernous  n?evi,  generally  situated 
on  the  soft  palate.  They  may  be  excised,  or,  better  still, 
treated  by  electrolysis. 

Aneurysm. — A  few  cases  of  aneurysm  of  the  descending 
palatine  artery  have  been  described,  in  all  instances  but 
one,  following  an  injury.  One  of  these  cases  occurred  in 
the  practice  of  Gross.  The  patient  was  a  young  army 
officer  who  had  been  accidentally  stabbed  with  a  small  knife 
two  months  previously.  A  cure  was  promptly  effected  by 
laying  open  the  tumour  and  tying  the  artery  at  both 
ends. 


ADENOMATA    OF    THE    PALATE.  251 

Papillomata. — These  may  be  of  two  kinds,  pedunculated 
and  sessile.  The  pedunculated  papillomata  are  delicate 
polypoid  growths,  always  attached  to  the  soft  palate,  occur- 
ring in  adults,  generally  in  men.  Such  a  growth  was  met 
with  in  the  case  of  a  healthy  girl,  aged  eighteen,  who  came 
to  the  Dental  Hospital,  Leicester  Square,  to  have  some  teeth 
stopped  ;  on  examining  her  mouth,  Mr.  Ackery  noticed  a 
growth  attached  to  the  soft  palate.  It  was  pedunculated, 
hanging  down  beyond  the  margin  of  the  left  velum,  and  had 
a  warty  appearance  :  he  snipped  it  off  with  scissors,  and 
rather  free  haemorrhage  followed.  The  growth  was  about 
half  an  inch  long  by  one-sixth  of  an  inch  broad,  the  pedicle 
being  about  one-eighth  of  an  inch  thick  ;  it  was  of  the  same 
colour  as  the  surrounding  mucous  membrane,  and  the  sur- 
face was  composed  of  enlarged  fungiform  and  filiform 
papillse.  On  a  longitudinal  section  it  was  seen  to  be  com- 
posed of  compound  papillse  branching  off  from  a  common 
root  or  base,  each  offshoot  being  composed  of  dilated  blood- 
vessels, surrounded  by  a  very  small  amount  of  connective 
tissue,  and  enclosed  by  a  thin  layer  of  mucous  membrane, 
on  which  were  several  layers  of  epithelium  cells  of  the 
squamous  variety. 

The  sessile  tumours  or  warty  papillomata  may  be  found 
on  the  hard  palate,  and  may  extend  widely  to  the  whole 
palate.  It  is  probable  that  they  occur  as  a  result  of  chronic 
or  syphilitic  pharyngitis.  The  only  satisfactory  treatment 
is  free  removal  of  the  growth  (see  p.  233). 

Adenomata. — According  to  Stephen  Paget,  "  There  is  much 
uncertainty  as  to  these  tumours  of  the  palate ;  it  appears 
to  be  a  name  given  to  any  solid  indolent  innocent  sessile 
tumour,  without  much  regard  to  microscopic  structure.  In 
most  of  the  recorded  cases  there  is  no  account  of  micro- 
scopical appearances,  and  the  accounts  that  in  other  cases  are 
given  do  not  appear  to  have  much  in  common.  In  two 
cases  lately  reported  by  the  writer  to  the  Pathological  So- 
ciety, where  the  history,  manner  of  growth,  and  naked-eye 
appearances  of  the  tumours  made  it  certain  that  they  were 
absolutely  innocent,  there  were  masses  of  epithelial  cells  with 


252  TUMOUES    OF    THE   PALATE. 

cell-nests.  The  word  '  adenoma  '  applied  to  tumours  of  the 
palate  has  only  a  clinical  value  ;  it  means  only  an  innocent 
tumour,  very  slow  in  growth,  firm,  limited,  and,  as  a  rule, 
shelling-out  easily." 

Dr.  Cabot  showed  to  the  Boston  Society  for  Medical 
Improvement  a  small  round  tumour,  which  he  had  removed 
from  the  roof  of  the  mouth  of  a  soldier.  It  had  existed  for 
eighteen  months,  and  was  situated  in  the  posterior  and  left 
part  of  the  hard  palate,  extending  as  far  as,  but  not  involving, 
the  gum.  Although  the  patient  had  suffered  severe  pain  in 
the  left  side  of  the  face  and  temple  of  a  neuralgic  character, 
yet  he  was  not  sure  that  it  had  its  origin  in  the  tumour. 
It  was  somewhat  tender  on  pressure,  but  not  painful.  The 
capsule  which  contained  it  being  incised,  it  was  easily  shelled 
out.  It  was  two-thirds  of  an  inch  in  diameter,  of  a  yellowish 
white  colour  and  mostly  smooth,  but  in  one  part  it  had  a 
warty  appearance. 

In  1879  I  ^^^  under  my  care  a  lady  with  a  very 
suspicious  tumour  of  the  soft  palate,  which  I  feared  would 
prove  to  be  sarcomatous.  On  incising  it,  however,  I  was  able 
to  enucleate  with  the  finger  what  proved  to  be  an  adenoma 
or  hypertrophy  of  the  glands  of  the  soft  palate,  contained 
in  a  distinct  capsule,  which  I  was  also  able  to  withdraw. 
The  patient  has  remained  in  perfect  health  to  the  present 
time. 

Sarcomata. — Here  again  we  cannot  do  better  than  quote 
an  extract  from  Mr.  Stephen  Paget's  valuable  paper. 
"  Though  it  is  impossible  to  draw  a  clear  line  betM^een  true 
sarcoma  of  the  palate  and  such  mixed  growths  as  '  cystic 
adeno-sarcoma,'  and  '  adeno-myxoma,'  and  again  between 
these  mixed  growths  and  the  '  adenomata ' ;  yet  the  sarco- 
mata of  the  palate  are  a  well-marked  group.  They  are 
more  rare  than  the  innocent  tumours ;  they  occur  equally  in 
men  and  in  women,  and  more  often  in  the  soft  palate  than 
in  the  hard.  The  average  age  when  the  growths  were  first 
observed  was  over  forty.  The  average  duration  of  each 
tumour  before  surgical  aid  was  sought  was  two  years,  if  we 


SARCOMA    OF    THE    PALATE. 


•10  6 


except  one  case  where  the  tumour  began  to  grow  rapidly 
after  many  years  lying  quiet.  Here  we  have  two  clear 
differences  between  the  '  adenomata '  and  the  '  sarco- 
mata.' " 

A  case  of  sarcoma  of  the  hard  palate  came  under  my 
care  in  1876.  The  patient  was  a  woman,  aged  forty-eight, 
and  stated  that  she  had  noticed  a  small  lump  on  the  hard 
palate  since  childhood,  but  it  gave  her  no  inconvenience 


Fig.  113. 


until  about  two  years  ago,  when  it  began  to  enlarge,  and 
from  this  time  it  steadily  grew,  and  soon  began  to  interfere 
with  her  articulation.  Her  health  had,  however,  always 
been  good.  There  was  no  history  of  tumour  in  the  family. 
The  tumour  filled  up  tlie  hollow  in  the  hard  palate,  being 
more  attached  to  the  left  side,  where  the  mucous  membrane 
was  continued  directly  over  it,  than  on  the  right,  where  a 
probe  could  be  passed  between  the  tumour  and  the  palate. 
It  was  about  the  size  of  a  horse-chestnut,  slightly  lobed  on 
the  surface,  elastic,  but  not  fluctuating  ;  the  mucous  mem- 
brane over   it  was  not  adherent  to   it,  and  was    normal  in 


254  TUMOUKS    OF    THE    PALATE. 

appearance.  The  tumour  moved  slightly  over  the  bone. 
There  were  no  enlarged  lymphatic  glands  in  the  neck.  The 
accompanying  woodcut  (Fig.  113)  was  made  from  a  plaster 
cast  taken  by  a  dentist. 

I  removed  the  tumour  by  making  an  incision  round  the 
left  side  of  the  growth,  which  then  readily  shelled  out  from 
a  distinct  capsule  ;  the  capsule  itself  was  afterwards  removed 
with  the  fingers.  Bleeding  was  stopped  by  the  actual 
cautery.  The  wound  granulated,  but  left  a  part  of  the  hard 
palate  bare.  A  small  portion  of  this  was  loose  when  the 
patient  left  the  hospital,  and  she  stated  that  when  she  drank 
fluid  came  into  the  left  nostril. 

The  tumour  was  examined  microscopically,  and  found  to 
be  a  small  round-celled  sarcoma. 

A  very  similar  tumour,  removed  by  Sir  W.  Fergusson,  is 
preserved  in  the  Museum  of  the  College  of  Surgeons.  It  is 
a  round-celled  sarcoma,  half  an  inch  in  diameter,  removed 
from  a  woman  of  thirty-five,  in  whom  it  had  been  growing 
for  four  years. 

In  1880  I  saw,  with  Sir  J.  Paget,  a  child,  aged  seven, 
with  a  tumour  presenting  almost  precisely  similar  appear- 
ances to  the  adenomatous  tumour  described  on  page  252. 
On  cutting  into  the  growth,  however,  it  proved  to  be  a 
sarcoma,  with  extensive  attachments,  which  did  not  admit  of 
removal.  The  growth  steadily  increased  and  destroyed  life 
in  six  months. 

Looking  back  at  these  two  cases,  I  find  it  impossible  to 
give  any  symptom  by  which  they  might  have  been  dis- 
tinguished ;  but  the  duration  of  the  growth,  if  it  can  be 
accurately  ascertained,  would  doubtless  help  at  arriving  at  a 
just  conclusion. 

Carcinomata. — True  cancers  of  the  palate  are  but  seldom 
met  with.  They  are  of  two  kinds :  one,  squamous  epithe- 
lioma, commencing  in  the  epithelium  covering  the  palate  ; 
the  other,  glandular  carcinoma,  commencing  underneath  the 
epithelium,  originating,  in  all  probability,  in  one  of  the 
numerous  glands  situated  in  the  palate. 


CARCINOMA    OF    THE    PALATE.  255 

The  squamous  epithelioma  of  the  palate  is  often  a  secon- 
dary infection  of  the  palate,  the  primary  growth  having 
commenced  in  the  gum.  Such  cases  are  really  epitheliomata 
of  the  gum,  extending  later  on  to  the  palate.  Sometimes, 
however,  a  primary  epithelioma  of  the  palate  is  met  with. 
Thus,  Brissaud,  in  the  Bull.  Soc.  Anatovi.,  1872,  relates  the 
case  of  a  man,  aged  forty-five,  who  had  psoriasis  of  the 
palate  for  fifteen  years,  prohahly  caused  by  excessive  smoking, 
in  which  epitheliomatous  ulceration  set  in. 

Glandular  carcinoma,  or,  as  it  is  sometimes  termed, 
medullary  carcinoma,  of  the  palate  is  very  rare.  Stephen 
Paget  could  collect  only  three  cases.  The  first  case 
was  reported  by  Mr.  Shaw  in  the  sixth  volume  of  the 
Pathological  Society's  Transactions.  It  occurred  in  a  woman, 
aged  fifty-three,  who  had  noticed  the  tumour  for  one  year. 
On  examination  the  growth  was  found  to  be  inseparably 
connected  with  the  hard  and  soft  palate,  lying  in  front  of 
the  right  tonsil;  lymphatic  glands,  extensively  involved, 
rendering  operation  impossible. 

The  second  case  is  thus  reported  by  Stephen  Paget : 
"A  man,  aged  fifty-nine.  Disease  noticed  three  months. 
He  has  a  tumour  in  the  left  half  of  his  soft  palate,  the  size 
of  a  large  walnut,  pushing  down  between  the  pillars  of  the 
fauces  ;  soft,  almost  fluctuating.  The  mucous  membrane  over 
it  is  slightly  congested,  and  a  few  large  veins  can  be  seen 
in  it.  No  glands  are  felt  at  the  angle  of  the  jaw.  He  has 
difficulty  of  breathing,  and  can  only  swallow  fluids.  Mr. 
Langton  made  an  incision  over  it,  which  was  followed  by 
profuse  htemorrhage.  The  growth  was  easily  enucleated, 
except  toward  the  horizontal  plate,  where  its  attachment 
was  more  firm.  The  wound  was  sutured.  Eecurrence  six 
weeks  after  the  operation.     Death  three  weeks  later. 

"  Post-mortem. — A  mass  in  the  palate  the  size  of  a  Tan- 
gerine orange  ;  not  found  to  be  connected  with  the  bone. 
Soft,  lobulated,  medullary  cancer.  Cervical  and  mediastinal 
glands  infiltrated,  and  cancerous  deposits  over  both  lungs. 
(Mr.  Langton,  Clin.  Soc.  Trans.,  iii)." 


256  TUMOUES    OF    THE    PALATE. 

The  third  case  was  under  the  care  of  Mr.  Treves.  It 
occurred  in  a  man,  aged  fifty-six.  A  tumour  had  been 
noticed  in  the  right  half  of  his  soft  palate  for  two  months. 
It  was  the  size  of  a  chestnut,  and  was  touching  the  pharynx. 
Mr.  Treves  ligatured  the  common  carotid  artery,  and  removed 
the  right  half  of  the  soft  palate  with  the  tumour  and  an  en- 
larged gland  from  the  angle  of  the  jaw.  The  man  recovered. 
The  growth  was  found  to  be  a  '  spheroidal-celled '  or  glan- 
dular carcinoma,  partly  encapsuled. 


CHAPTEE   XVI. 

NON-MALIGNANT   TUMOUES   OF    THE  UPPEE   JAW. 


Fibroma,  Encliondroma,  Osteoma. 

With  regard  to  the  statistics  of  tumours  of  the  upper  jaw, 
I  shall  content  myself  with  quoting  0.  Weber,  who  has 
collected  307  cases  from  the  following  sources:  183  cases 
tabulated  by  Heyf elder  ;  36  recorded  by  Liicke  from  Langen- 
beck's  clinique  ;  1 7  reported  in  the  Medical  Times  and  Gazette 
(September  3rd,  1859);  and  71  cases  either  observed  by 
himself  in  Wutzer's  clinique,  or  occurring  in  his  own  practice. 
Of  the  above  cases  there  were : 


Osseous  tumours     .          .          .          . 

•      32 

Vascular  tumour    .          .          .          . 

I 

Fibrous  tumours     . 

•      17 

Sarcomatous  tumours 

.      84 

Enchondromatous  tumours 

8 

Cystic  tumours 

.     20 

Mucous  polypi        ... 

7 

Carcinoma     .... 

■    133 

Melanosis     .... 

5 

307 

In  commenting  upon  this  table,  Weber  very  justly  remarks 
that  doubtless  the  list  of  cancerous  cases  is  exaggerated,  and 
suggests  that  a  fair  estimate  would  be  gained  by  allotting 
rather  more  than  a  third  of  the  whole  number  to  sarcoma- 
tous tumours  ;  less  than  one-third  to  the  cancerous ;  and  the 
remainder  to  the  osseous  tumours,  cysts,  &c. 

E 


258         NON-MALIGNANT    TUMOURS    OF   THE   UPPER   JAW. 

It  must  be  borne  in  mind,  however,  that  modern  methods 
of  investigation  have  shown  that  the  old  classifications  are 
frequently  based  upon  erroneous  data,  so  that  a  re-arrange- 
ment of  tumours  of  the  jaws  has  become  necessary,  and  will 
be  attempted  in  the  following  pages. 

Fibroma. — This  closely  resembles  the  fibrous  tumours 
found  in  other  parts  of  the  body.  It  is  dense  in  structure 
but  not  unfrequently  lobulated,  and,  on  section,  slender 
bundles  of  intersecting  fibres  may  occasionally  be  traced  in 
them,  of  which  there  are  good  examples  in  the  Museum  of 
the  College  of  Surgeons.  The  fibrous  tumour  usually  springs 
from  one  of  two  situations — either  the  interior  of  the  antrum 
or  from  some  portion  of  the  alveolus.  In  both  cases  it  is 
intimately  connected  with  the  periosteum,  in  this  respect 
resembling  epulis.  Occasionally  the  growth  appears  to 
follow  some  slight  injury,  as  in  the  case  of  a  lady,  a  patient 
of  Dr.  Xeale,  from  whom,  in  1870,  I  successfully  removed 
a  fibrous  tumour  occupying  the  interior  of  the  antrum, 
which  had  followed  a  blow  given  by  her  child,  and  which 
may  have  been  a  fibrous  odontoma  (p.  264). 

Fibroma  grows  slowly  but  surely,  involving  in  its  progress 
the  surrounding  structures.  When  arising  in  the  antrum, 
it  first  expands  the  walls  of  that  cavity,  bulging  out  the 
face  and  forming  tumours  in  the  palate  and  floor  of  the 
orbit,  and  subsequently  produces  absorption  of  the  osseous 
walls  and  spreads  unchecked  in  all  directions.  The  follow- 
ing description  of  a  specimen  in  St.  George's  Hospital 
Museum  gives  a  good  idea  of  the  ravages  of  such  a 
tumour  :  "  Fibrous  tumour  growing  from  the  antrum,  and 
making  its  way  by  the  absorption  of  the  walls  of  that 
cavity  in  different  directions.  It  projects  upwards  into  the 
orbit,  destroying  the  floor  of  that  cavity,  and  protruding 
from  its  inner  margin  forwards  on  to  the  cheek.  It  has 
also  destroyed  the  anterior  wall  of  the  antrum,  and  dis- 
placed the  malar  bone  forward  and  outward;  inwards  it 
projects  into  the  nose  beneath  the  middle  turbinated  bone, 
and  downwards  it  makes  its  appearance  on  the  under  sur- 
face of  the  alveolar  process  in  the  form  of  a  rounded  mass, 


FIBllOMA    OF   THE   UPPER    JAW.  259 

destroying  the  floor  of  the  antrum  in  the  neighbourhood  of 
the  front  molar  tooth.  Behind,  the  tumour  appears  in  the 
zygomatic  fossa  by  the  absorption  of  the  outer  part  of  the 
tuberosity  of  the  superior  maxillary  bone.  The  tumour  is 
composed  of  circular  nuclei  of  various  sizes,  and  spindle- 
shaped  fibres.  The  patient  from  whom  the  specimen  was 
taken,  William  H.,  died  of  arachnitis,  and  softening  of  the 
corresponding  part  of  the  brain." — Catalogue  of  St.  Georges 
Hospital  Museum. 

When  it  arises  from  the  alveolus,  a  fibrous  tumour  may 
encroach  on  both  the  facial  and  the  palatine  surfaces  of  the 
jaw,   crushing  in  the  antrum  although    not    involving    its 

Fig.  114. 


interior.  Of  this  a  good  example  is  seen  in  a  preparation  in 
the  College  of  Surgeons,  of  an  upper  jaw  removed  by  Mr. 
Listen.  Here  the  tumour  which  is  affixed  to  the  alveolar 
border,  near  the  molar  teeth,  extends  inwards  so  as  to  cover 
the  palatine  portion  of  the  jaw,  and  outwards  so  as  to  conceal 
all  the  bicuspid  and  molar  teeth,  with  the  exception  of  the 
last.  The  walls  of  the  antrum  are  pressed  inwards,  but  its 
interior  is  healthy.  The  patient  was  a  woman,  thirty  years 
old,  and  the  tumour  was  observed  four  years  before  its 
removal,  which  was  successful.  On  the  other  hand,  fibrous 
tumours,  though  commencing  in  the  alveolus,  may  secondarily 
involve  the  antrum  when  they  have  attained  considerable 
size,  producing  complete  absorption  of  its  walls,  and  project- 
ing into  the  nose  and  through  the  palate.  Of  this  a 
preparation  in  the  College  of  Surgeons'  Museum,  of  an  upper 


260 


NON-MALIGNANT   TUMOUES    OF   THE    UPPER    JAW. 


jaw,  also  removed  by  Mr,  Liston,  affords  a  good  example. 
Here  the  patient  was  only  twenty-one,  and  the  growth  first 
appeared  on  the  outer  side  of  the  gum  of  the  left  upper  jaw 
four  years  before  the  operation.  It  was  cut  off  six  months 
after  its  first  appearance,  but  returned,  and  eighteen  months 
after  was  removed,  with  a  portion  of  the  alveolar  process, 
but  reappeared  in  a  few  weeks.  Fig.  114,  from  Listen's 
"Practical  Surgery,"  shows  the  growth  after  its  removal,  and 


Fig.  115. 


Fig.  116. 


r-,>^i 


Eigs.  115  and  116  show  the  patient  before  and  after  the 
operation.  It  may  be  noticed  here,  as  in  the  case  of  a  large 
epulis,  that  disease  of  the  upper  jaw  often  closely  resembles, 
externally,  a  tumour  of  the  inferior  maxilla. 

The  case  is  given  by  Mr.  Liston  in  his  paper  on  "Tumours 
of  the  Jaw,"  in  the  Medico-Chirurgical  Transactions,  vol.  xx. 

The  enormous  size  to  which  fibrous  tumours  of  the  upper 
jaw  may  grow  without  destroying  the  patient,  is  well  seen 
in  the  accompanying  drawing  (Fig.  117)  of  Mr.  Listen's 
celebrated  case  of  Mrs.  Frazer,  from  whom  that  eminent 
surgeon  successfully  removed  the  growth.  The  tumour  is 
preserved  in  the  Museum  of  the  College  of  Surgeons,  and  its 


FIBKOMA    OF    THE   UPPER    JAW. 


261 


diameters  are,  vertically,  seven  inches ;  transversely,  seven 
inches  ;  from  before  backwards,  nearly  six  inches.  Contrary 
to  the  ordinary  practice,  a  portion  of  the  integument  was 
removed  with  the  tumour,  measuring  twelve  inches  in  length 
and  ten  in  breadth,  and  this  left  a  gap  in  the  skin  of  the 
face  upon  the  patient's  recovery,  a  point  which  will  be  again 
referred  to.  The  growth  of  this  tumour  was  connected 
apparently  in  a  curious  way  with  the  performance  of  the 

Fig.  117. 


uterine  functions.  The  patient  was  forty  years  old,  and  the 
tumour  began  to  grow  six  years  before  its  removal,  in 
consequence  of  a  blow  in  the  region  of  the  antrum.  Its 
progress  at  first  was  slow  and  not  painful,  but  at  the  end  of 
two  years  a  distinct  tumour  was  felt  in  the  cheek.  During 
the  next  two  years  it  grew  rapidly,  especially  during  a  period 
of  gestation,  but  still  without  much  pain.  In  the  fifth 
year  of  its  growth  she  bore  a  second  child,  after  which 
the  catamenia  ceased  to  flow,  and  the  tumour  was  subject 
to    monthly   augmentations    of    its  vascularity,  and   slight 


262         NON-MALIGNANT   TUMOURS    OF    THE   UPPER   JAW. 

hsemorrliages  occurred  from  its  inner,  though  not  ulcerated, 
surface,  and  from  the  adjacent  parts  of  the  gum.  The  case 
is  given  in  detail  in  Mr.  Listen's  paper  already  referred  to. 

A  remarkable  feature,  noticed  in  a  case  of  fibrous  tumour 
of  the  antrum,  in  a  young  man  of  eighteen,  under  the  care 
of  Sir  J.  Paget,  in  i860,  was  a  distinct  pulsation  in  a 
portion  of  the  tumour  which  projected  into  the  orbit.  The 
pulsation  was  slight  but  decided,  and  was  synchronous  with 
the  radial  pulse.  The  case  was  clearly  not  one  of  malignant 
disease,  but  proved  upon  removal  to  be  an  ordinary  fibrous 
tumour.  No  satisfactory  explanation  seems  possible  of  the 
case,  which  I  believe  to  be  unique.  Suppuration  has 
occurred  in  connection  with  fibrous  tumours  of  the  jaw,  but 
only,  I  believe,  when  they  have  been  punctured  with  a  view 
to  exploration  and  diagnosis.  Of  this  the  tumour  removed 
from  Janet  Campbell  and  preserved  in  the  Museum  of  the 
College  of  Surgeons,  is  an  example.  Simple  fibrous  tumours 
occasionally  recur  after  removal,  but  it  is  doubtful  whether 
in  these  cases  the  whole  of  the  disease  has  been  eradicated. 
According  to  0.  Weber  they  are  usually  connected  with  the 
lining  of  the  Haversian  canals  of  the  surrounding  bone,  and 
though  he  believes  that  these  processes  may  sometimes  be 
effectually  detached,  he  advises  the  practice  ordinarily  fol- 
lowed of  removing  a  portion  of  bone. 

I  think  it  right  to  mention  here  that  all  the  specimens 
removed  by  Mr.  Listen,  and  referred  to  in  the  foregoing 
pages,  have,  in  the  new  catalogue  of  the  College  of  Surgeons' 
Museum,  been  placed  among  the  sarcomata,  on  what  I  cannot 
but  regard  as  insufficient  grounds.  In  the  first  place,  forty 
years'  soaking  in  spirit  prevents  anything  like  a  reliable 
microscopic  examination,  and  the  presence  of  a  few  cells 
scattered  among  the  fibres  of  a  tumour  is  no  proof  that  it 
is  not  a  fibrous  tumour ;  and,  secondly,  the  clinical  history 
of  all  these  cases  is  that  of  a  simple  growth,  which  once 
removed  did  not  recur.  I  have  therefore  included  them 
among  the  fibrous  tumours,  and  if  they  are  not  so,  it  is  very 
remarkable  that  there  is  no  specimen  of  the  true  fibrous 
tumour  of  the  upper  jaw  among  the  large  number  removed 


FIBKOMA    OF    THE    UPPEK    JAW.  263 

by  Liston  and  preserved  in  the  College  of  Surgeons'  and  in 
University  College  Museums. 

Fibrous  tumours  of  the  jaw,  like  those  in  other  parts  of 
the  body,  and  especially  in  the  uterus,  are  liable  to  calca- 
reous degeneration,  or,  as  is  sometimes  incorrectly  stated,  to 
ossific  deposit.  A  good  specimen  of  the  kind  is  preserved, 
in  the  Museum  of  St.  Thomas's  Hospital,  and  is  thus 
described  in  the  Museum  catalogue  : 

"  An  osteo-fibrous  tumour  of  the  antrum,  removed  by  Mr. 
Solly.  The  tumour  entirely  filled  the  cavity  of  the  antrum, 
the  bony  parietes  of  which  have  been  absorbed  to  a  con- 
siderable extent ;  it  protruded  the  cheek  anteriorly,  projected 
into  the  fauces  posteriorly,  pressed  down  the  palate  in- 
feriorly,  and  extended  to  the  septum  nasi  internally.  Its 
firmest  point  of  attachment  is  to  that  part  of  the  antrum 
corresponding  to  the  roots  of  the  first  molar,  canine,  and 
incisor  teeth.  The  tumour  is  of  a  rounded  form,  and  has  a 
smooth  external  surface ;  its  section  presents  very  much  the 
appearance  of  a  fibrous  tumour  of  the  uterus  of  slow  growth, 
and  contains  an  abundance  of  bony  deposit. 

"From  a  boy,  aged  seventeen.  The  existence  of  the 
tumour  was  discovered  only  ten  months  previous  to  its 
removal,  when  the  face  began  to  swell,  the  swelling  being 
accompanied  by  pain.  JSTo  untoward  circumstances  followed 
the  operation,  and  the  boy  left  the  hospital  quite  well.  The 
deformity  was  very  slight.  Five  years  after  the  operation 
the  boy  was  in  capital  health."  More  complete  details  of 
the  case  will  be  found  in  Mr.  Solly's  "  Surgical  Experiences," 
lecture  41. 

A  remarkable  example  of  calcareous  degeneration  of  a 
fibrous  tumour  occurred  in  the  practice  of  Sir  W.  Fergusson, 
and  the  preparation  is  now  in  the  Museum  of  the  College  of 
Surgeons.  It  is  a  fibrous  tumour  of  the  left  upper  jaw,  of 
some  years*  growth,  from  a  woman,  aged  fifty,  containing 
numerous  calcareous  particles  and  acicular  crystals,  and  in 
addition,  enclosing  a  suppurating  cavity,  in  which  was  a  mass 
about  an  inch  in  diameter,  found  by  Dr.  Goodhart  to 
consist  of  acicular   crystals   of   mineral   matter,  entangling 


264        NON-MALIGNANT   TUMOURS    OF   THE  UPPER   JAW. 

in  places  nucleated  and  shrivelled  cells.  This  is  clearly  an 
example  of  extreme  calcareous  degeneration  undergoing 
necrosis. 

With  regard  to  the  causes  giving  rise  to  fibrous  tumours 
of  the  upper  jaw  there  is  much  obscurity,  though  there  is 
little  doubt  that  they  in  many  cases  originate  in  some 
irritation  due  either  to  a  blow,  or  more  frequently  to  the 
presence  of  decayed  teeth ;  and  the  latter  may  give  rise  to  a 
tumour  commencing  in  the  alveolus  itself  or  within  the 
antrum,  the  lining  membrane  of  which  is  irritated  by  the 
fangs  of  the  diseased  teeth.  Bordenave  strongly  insisted 
upon  this,  and  since  his  time  most  surgeons  have  taken  the 
same  view.  Stanley  mentions  a  case  which  occurrred  to  Mr. 
Luke,  in  which  a  black,  carious  tooth  was  found  imbedded 
in  a  fibrous  tumour  of  the  upper  jaw,  and  other  cases  of  the 
kind  have  occurred,  although  the  event  is  more  common  in 
the  lower  jaw. 

Since  the  publication  of  the  first  edition  of  this  work, 
M.  Broca,  in    his  TraiU  des  Tumeurs  (Paris,    1869),   put 
forward  the  view  that  many  cases  of  fibrous  and  fibro-cellular 
tumour   of   both   upper   and   lower  jaw   depend   upon   the 
growth  of  a  tooth-germ,  and  these  are  included  by  him  under 
the  head  of  odontomes  emhryo-plastiques.      There  is  no  differ- 
ence in  structure  by  which  these  fibrous  odontomata  can  be 
distinguished  from  the  ordinary  fibrous  tumour,  but  according 
to  M.  Broca  they  are  always  encysted,  and  they  occur  only 
in   young   subjects,  and   before   the   last   tooth   is   formed. 
Owing  to  their  ready  enucleation,  these  tumours  show  no 
tendency  to  recur.     I  have  met  with  but  one  case  which 
seemed  in  any  way  to  support  the  views  above  given.     A 
young  married  lady,  a  patient  of  Dr.  ISTeale,  had  a  tumour  of 
the  upper  jaw,  evidently  due  to  expansion  of  the  antrum, 
the  walls  of  which  crackled  under  pressure.     Believing  the 
swelling  to  be  due  to  fluid,  I  punctured  it,  giving  exit  to 
only  a   small   quantity  of  fluid,  and  discovered  a  tumour 
within.    On  laying  open  the  antrum,  I  was  able  to  enucleate 
with  the  finger  a  tumour  which  had  very  slight  attachments, 
presented  all  the  appearance  of  a  fibroma,  and  on  examina- 


ENCHONDKOMA    OF    THE   UPPER    JAW.  265 

tion  by  Dr.  Jkstian,  was  pronounced  to  be  very  rich  in 
cell  elements,  and  therefore  likely  to  recur.  Nevertheless, 
the  patient  was  in  perfect  health  fourteen  years  after  the 
operation. 

Emhondromci  of  the  upper  jaw  is  of  uncommon  occur- 
rence, but  the  jaw  may  become  involved  in  cartilaginous 
tumours  springing  from  other  bones  of  the  face.  Of  this 
there  is  an  example  in  St.  George's  Hospital  Museum, 
taken  from  a  young  woman,  who,  seven  years  before  her 
death,  began  to  suffer  from  soft  elastic  tumours  on  the  inner 
sides  of  the  orbits.  Two  years  after,  the  right  maxillary 
bone  was  fuller  below  the  orbit  than  the  left,  and  the  right 
half  of  the  bony  palate  was  larger  and  more  depressed  than 
the  other ;  but  in  neither  of  these  parts  was  there  any 
softening.  Gradually  the  eyeballs  were  protruded,  and  the 
sight  was  lost.  Two  years  later,  it  was  noticed  that  the 
superior  maxillary  bones  projected  nearly  an  inch  beyond  the 
inferior,  so  that  she  had  some  difficulty  in  masticating.  A 
portrait  of  this  patient  is  preserved  in  St.  George's  Museum. 
The  tumour  was  found  to  project  into  the  cranium,  the 
orbits,  the  antra,  and  the  nasal,  zygomatic,  and  pterygo- 
maxillary  fossas.  All  the  fossee  were  quite  filled  up  by  the 
growth,  and  the  bones  of  the  face  and  orbits  extensively 
absorbed.  The  hard  palate  was  pressed  downwards,  so  that 
the  teeth  on  the  two  sides  deviated  from  their  natural  line, 
and  the  left  central  incisor  crossed  that  of  the  right  side. 
Microscopical  examination  of  the  tumour  showed  it  to  be 
composed  principally  of  cartilage.  A  full  description,  with 
a  lithograph  of  the  preparation,  will  be  found  in  the  Patho- 
logical Society^ s  Transactions,  vol.  x. 

In  the  Museum  of  St.  Bartholomew's  Hospital  is  another 
post-mortem  specimen  of  cartilaginous  tumour  of  the  face, 
from  a  lad  of  sixteen,  occupying  the  situation  of  the 
superior  maxillary  bones,  which  are  completely  absorbed. 
Above,  the  tumour  has  extended  through  the  left  side  of  the 
base  of  the  skull  into  its  cavity,  where  it  forms  a  large  pro- 
jection in  the  situation  of  the  anterior  lobes  of  the  cerebrum  ; 
below,  it  is  united  to  the  soft  palate ;  in  front,  it  protrudes 


266         NON-MALIGNANT    TUMOUES    OF    THE    UPPER    JAW. 

and  distends  the  left  nostril,  and  has  caused  the  ulceration 
of  a  part  of  the  integuments  of  the  face.  The  outer  surface 
of  the  tumour  is  nodulated,  its  interior,  shown  by  the  sec- 
tion, is  formed  of  close-set  nodules  and  masses  of  cartilage, 
partially  and  irregularly  ossified,  and  in  some  parts  intersected 
by  layers  of  a  softer,  probably  fibrous  tissue.  A  portion  of 
its  external  surface  projecting  below  the  left  nostril  has 
sloughed.  This  case  is  drawn  in  Mr.  Stanley's  illustrations 
to  his  work  on  "  Diseases  of  the  Bones  " ;  and  both  it  and 
the  preceding  preparation  illustrate  very  well  the  tendency 
of  cartilaginous  tumours  to  invade  all  the  surrounding 
structures,  and  to  fill  the  several  cavities. 

A  remarkable  case  of  recurrent  cartilaginous  tumour  of 
the  face,  originating  in  the  upper  jaw,  was  under  my  own 
care,  of  which  the  following  are  the  particulars :  The 
patient,  aged  thirty-four,  was  admitted  into  University 
College  Hospital  on  the  ist  of  January,  1868,  with  a  large 
tumour  of  the  right  side  of  the  face.  When  about  seven- 
teen years  of  age  he  noticed  a  pimple  on  the  right  side  of 
the  nose,  which  increased  pretty  rapidly  ;  and  three  months 
after  (185 1)  he  went  into  St.  Thomas's  Hospital,  when  Mr. 
Le  Gros  Clark  operated,  and  removed  a  tumour  as  large  as  a 
walnut.  He  quite  recovered,  and  was  well  for  a  few  months, 
but  within  a  year  the  tumour  had  returned.  He  was  then 
admitted  into  King's  College  Hospital,  under  Mr.  Partridge, 
who,  in  June,  1852,  removed  the  tumour,  which  was  of  an 
osteo-cartilaginous  character,  oblong  in  shape,  and  of  the 
size  of  a  large  walnut,  projecting  slightly  into  the  antrum, 
and  involving  the  nasal  process  of  the  superior  maxillary 
bone,  but  in  no  way  implicating  the  mouth  or  orbit.  Erom 
this  operation  the  patient  made  a  good  recovery,  except  that 
a  small  fistulous  opening  was  left  in  the  cheek.  The  man 
continued  in  good  health  until  1857,  when  he  went  to 
America,  and  soon  after  arriving  there  he  found  the  tumour 
beginning  to  appear  again,  and  in  i860  Professor  Gunn 
operated  at  Anne  Harbour,  in  the  State  of  Michigan,  and 
removed  the  entire  right  upper  jaw.  The  tumour,  however, 
began  to  grow  again  rapidly,  and  projected  on  the  face.    The 


ENCHONDEOMA    OF    THE    UPPER    JAW. 


267 


surgeons  at  Maple  Eapicls,  where  the  patient  lived,  wanted 
to  operate  again,  bvit  he  declined,  and  returned  to  England  in 
1865.  Soon  after  this  an  abscess  formed  in  the  upper  part 
of  the  tumour,  which  was  lanced  with  great  relief,  but  the 
incision  thus  made  had  never  closed,  owing  to  the  stretching 
of  the  skin  by  the  tumour. 

The  patient's  appearance  on  admission  was  most  unsightly 
(Fig,  1 1 8),  the  right  side  of  the  face  being  greatly  disfigured 

Fig.  118. 


by  a  large  tumour,  by  which  the  eye  was  thrust  completely 
aside,  but  without  loss  of  vision.  Immediately  to  the  inner 
side  of  the  eye  was  an  open  granulating  sore  of  the  size  of 
a  florin,  the  result  of  the  incision  for  the  evacuation  of  matter 
already  referred  to.  The  tumour  appeared  externally  to  con- 
sist of  two  portions,  separated  by  a  horizontal  sulcus,  at  the 
bottom  of  which  the  fistulous  opening  resulting  from  the 
second  operation  was  still  visible.  The  upper  and  more 
prominent  portion  had  invaded  the  orbit,  reaching  to  its 
upper  border,  and  extending  beyond  the  middle  line  of  the 
nose.  A  small  portion  of  this  had,  within  the  previous  two 
months,  projected  through  the  left  nasal  bone.     The  lower 


268         NOJSr-MALIGNANT    TUMOURS    OF    THE    UPPER    JAW. 

portion  of  the  tumour  involved  the  ala  of  the  nose  and 
adjacent  portion  of  the  cheek,  both  of  which  were  much 
distorted ;  on  a  small  projecting  portion  of  this  the  skin  was 
adherent.  Both  nostrils  were  completely  blocked,  and  had 
been  so  for  months.  Within  the  mouth  it  was  seen  that 
the  whole  of  the  right  side  of  the  hard  palate  had  been 
removed ;  and  in  its  place  there  was  a  smooth,  red,  oval 
mass,  coming  down  to  the  level  of  the  teeth  of  the  opposite 
side.  The  scars  in  the  middle  line  of  the  lip  and  on  the 
cheek,  resulting  from  former  operations,  were  still  visible. 
The  tumour  was  solid  and  not  tender  to  the  touch,  the  most 
prominent  point  being  apparently  osseous.  There  was  no 
enlargement  of  the  glands  in  the  neck  or  elsewhere,  and  the 
man  appeared  in  good  health.  The  tumour  had  made 
decided  progress  within  the  previous  few  months,  and  he  was 
anxious  to  have  it  removed,  to  which,  after  a  consultation 
with  my  colleagues,  I  agreed. 

On  January  8th,  under  chloroform,  I  made  a  curved  incision 
below  the  eye  to  the  side  of  the  nose,  from  the  extremity  of 
which  a  vertical  incision  was  carried  down  the  face  and 
round  the  ala  of  the  nose  ;  and  the  lip  was  divided  in  the 
cicatrix  of  a  former  operation.  The  flap  was  then  dissected 
back,  and  with  it  a  hard  prominent  nodule  of  bone,  which 
became  detached  from  the  bulk  of  the  tumour.  The  tumour 
being  thus  exposed,  I  proceeded  to  enucleate  it  with  the 
fingers,  and  by  successive  efforts  removed  in  this  way  the 
upper  part  of  the  growth.  The  tumour  presenting  in  the 
mouth  was  found  to  be  held  by  a  firm  band  of  tissue  in  the 
position  of  the  gum,  and  after  dividing  this  I  was  able  to 
tear  out  the  growth,  and  also  a  portion  projecting  through 
the  posterior  nares  into  the  pharynx.  The  wound  having 
been  well  sponged  out  and  the  hsemorrhage  having  abated, 
the  portion  at  the  inner  side  of  the  orbit  was  removed,  and 
was  found  to  project  into  the  frontal  sinuses,  which  (par- 
ticularly the  right)  were  considerably  expanded.  With  one 
of  Langenbeck's  palate  spatulse  I  carefully  cleared  these  out, 
scraping  the  walls,  and  then  introduced  a  pledget  of  lint 
covered  with  a  paste  of   chloride   of  zinc  (to  which  a  string 


ENCHONDKOMA    OF    THE    UPPEK    JAW.  269 

was  attached),  iu  order  to  destroy  any  remaining  portion. 
This  was  the  only  part  from  which  the  growth  appeared  to 
have  arisen,  the  remainder  of  the  huge  cavity  left  by  the 
removal  of  the  growth  being  perfectly  smooth  and  healthy. 
The  septum  narium  was  found  to  be  completely  pushed  over 
to  the  left,  and  to  have  been  destroyed  at  the  upper  part  by 
a  projecting  lobule  of  the  growth,  which  had  pushed  through 
the  nasal  bone.  The  ala  of  the  nose  included  a  small  portion 
of  the  growth,  which  was  removed,  and  also  the  bony  nodule 
attached  to  the  flap,  the  upper  corner  of  which,  being  very 
thin  and  closely  involved  in  the  growth,  was  cut  off.  The 
wound  was  sponged  out  with  solution  of  chloride  of  zinc, 
and  all  hemorrhage  having  ceased  without  the  application 
of  any  ligatures,  the  lip  was  brought  together  with  hare-lip 
pins,  and  the  remainder  of  the  wound  with  wire  sutures. 
The  edges  of  the  gap  caused  by  the  opening  of  an  abscess 
some  months  back  were  brought  together,  but  finding  that 
tliis  prevented  the  patient  closing  his  eye,  I  subsequently 
removed  these  sutures.  Collodion  was  painted  over  the 
wound,  and  the  patient,  who  had  a  good  pulse,  was  carried 
to  bed. 

The  patient  recovered  from  the  operation,  and  progressed 

well  until  February  2nd,  when  erysipelas  developed  and  he 

died.     The  tumour  was  exhibited  at  the  Pathological  Society, 

and  was  referred  to  a  committee  of  investigation,  which  pro- 

'  nounced  it  to  be  an  enchondroma  undergoincp  ossification. 

Probably  the  largest  enchondroma  of  the  upper  jaw  ever 
submitted  to  operation  is  one  recorded  by  Mr.  O'Shaughnessy, 
in  his  essay  on  "  Diseases  of  the  Jaws  "  (i  844).  The  patient 
was  a  Hindoo,  aged  twenty-one,  who  had  a  tumour  of  the 
upper  jaw,  of  a  year's  growth  (?)  which  had  attained  an 
enormous  size,  as  shown  in  the  illustrations  of  the  work 
in  question,  looking  nearly  as  big  as  the  patient's  head. 
Mr.  O'Shaughnessy  removed  the  tumour,  which  weighed 
four  pounds,  and  was  nearly  globular  in  form,  having  at 
its  inferior  surface  a  deep  groove  into  which  the  lower 
jaw  sank.  On  section  it  proved  to  be  of  dense  fibro-carti- 
laginous  structure,  surrounded   by  a  thin  shell   of   bone   in 


270         NON-MALIGNANT   TUMOURS    OF   THE    UPPER    JAW. 

the  greater  part  of  its  extent.  The  patient  made  a  good 
recovery. 

These  cases  will  serve  to  illustrate  the  leading  features 
with  regard  to  enchondroma.  The  disease  appears  ordi- 
narily early  in  life,  springing  from  the  surface  of  the  bone, 
or  from  the  antrum,  and  then  making  steady  progress  either 
externally,  as  in  the  last-mentioned  case,  or  internally  as  in 
the  former  ones.  It  produces  absorption  of  the  bone  of  the 
maxillge  in  its  progress,  and  protrudes  beneath  the  skin, 
which,  however,  it  rarely,  if  ever,  involves.  Its  rate  of 
increase  is  ordinarily  slow,  and  there  must,  I  fancy,  be  some 
error  in  the  statement  of  Mr.  O'Shaughnessy's  patient,  since 
it  is  difficult  to  imagine  that  a  growth  of  that  enormous  size 
could  have  been  produced  in  one  year.  In  the  early  stage, 
the  enchondromatous  tumour  may  possibly  be  got  rid  of  by 
absorbent  applications;  thus,  Mr.  Stanley  (p.  147)  mentions 
the  case  of  a  female,  aged  twenty-eight,  who  had  a  round 
tumour  of  the  size  of  a  hazel-nut  on  the  front  of  the  maxilla, 
which  had  been  growing  some  months.  This  was  ascertained, 
by  the  introduction  of  a  needle,  to  be  composed  of  cartilage 
with  particles  of  bone  dispersed  through  it.  Under  the 
local  use  of  iodine  two-thirds  of  the  growth  disappeared  in 
the  course  of  a  few  weeks. 

Such  a  result  cannot  be  hoped  for  when  the  tumour  has 
attained  any  size,  but  provided  it  is  still  confined  to  the 
maxilla,  a  cartilaginous  tumour  is  a  favourable  one  for  re- 
moval, owing  to  its  solidity  and  rounded  form,  and  the  ease 
with  which  it  is  isolated.  The  first  case  in  which  M.  Gen- 
soul  removed  the  superior  maxilla  was  for  a  tumour  of  this 
kind.  Ordinarily  perfect  immunity  from  return  is  obtained, 
provided  the  whole  disease  has  been  extirpated. 

In  many  cases  of  enchondroma  a  certain  amount  of  fibrous 
tissue  is  found  mixed  with  the  cartilage,  and  in  some  cases, 
particularly  those  of  slow  growth  and  of  long  standing,  the 
fibrous  has,  to  the  naked  eye,  almost  replaced  the  cartilagi- 
nous element.  Of  this  an  enchondromatous  tumour,  removed 
by  Mr.  Square,  of  Plymouth,  in  November,  1866,  and  kindly 
given  me  by  that  gentleman,  is  an  excellent  example. 


ENCHONDROMA    OF    THE    UPPER   JAW.  271 

The  tumour  was  of  the  size  of  an  orange,  and  occupied 
the  right  superior  maxilla  of  a  woman,  aged  forty-seven.  It 
had  been  growing  ten  years,  and  Mr.  Square  successfully  re- 
moved it.  The  preparation  now  in  the  Museum  of  the 
College  of  Surgeons,  and  of  which  a  section  has  been  made, 
shows  a  surface  closely  resembling  a  fibrous  tumour,  but  in 
which  cartilage  cells  are  readily  found  under  the  microscope. 
The  preparation  shows  a  deep  groove  in  the  buccal  surface  of 
the  tumour  caused  by  the  teeth  of  the  lower  jaw. 

The  ossific  deposit,  beginning  at  several  separate  points, 
which  is  not  unfrequently  found  in  connection  with  enchon- 
dromata  of  other  parts  of  the  body,  may  take  place  in 
enchondroma  of  the  upper  jaw.  A  very  excellent  example 
of  this  was  published  by  the  late  Mr.  Maurice  Collis,  of 
Dublin  {DuUin  Quarterly  Journal,  August,  1867),  and  the 
appearance  of  the  patient  is  well  shown  in  the  lithographic 
illustrations  which  accompany  that  paper.  The  patient  was 
fifty  years  of  age,  and  the  disease  dated  from  his  fourteenth 
year.  It  grew  slowly  at  first,  but  latterly  had  increased 
with  considerable  rapidity.  The  tumour  was  firm  and  hard, 
but  painless  until  recently,  when  brow-ague  was  complained 
of.  The  sight  of  the  left  eye  was  lost,  the  left  nostril 
occluded,  and  hearing  on  that  side  somewhat  dull.  The 
tumour  had  expanded  the  cheek,  pushed  up  the  floor  of  the 
orbit,  and  depressed  the  hard  palate.  Mr.  Collis  successfully 
removed  the  growth,  and  the  patient  made  a  rapid  recovery. 
The  following  is  Mr.  Collis's  description  of  the  tumour : 

"  The  growth  commenced  in  the  antrum,  filled  it,  implicated 
its  walls,  extended  to  the  spongy  bones,  developing  itself 
layer  over  layer,  until  the  entire  nasal  cavity  was  filled.  It 
then  continued  to  grow,  producing  the  immense  deformity 
already  described.  Originally  it  had  probably  been  an  en- 
chondroma, but  as  years  advanced  it  ossified,  beginning  from 
the  centre.  The  outer  layers  of  the  new  growth  were  probably 
the  most  recent,  as  they  contained  some  fragments  of  im- 
perfect or  degenerate  cartilage.  The  whole  was  enclosed 
within  a  real  bony  layer,  derived  from  the  proper  tissue  of 
the  spongy  bones  and  of  the  walls  of  the  antrum." 


272         NON-MALIGNANT    TUMOUES    OF    THE    UPPEK    JAW. 

Osteoma. — The  simplest  form  of  osseous  tumour  of  the 
upper  jaw  is  a  hypertrophy  of  the  whole  or  of  some  portion 
of  the  bone.  A  case  of  Sir  William  Tergusson's  has  already 
been  referred  to  (p.  225),  in  which  this  result  was  due  to 
the  presence  of  a  tooth  imbedded  in  the  jaw;  but  the  same 
thing  may  happen  without  obvious  cause.  The  tumour  is 
slow  of  growth  and  painless,  and  upon  removal  shows  no 
deviation  from  the  ordinary  structure  of  healthy  bone.  An 
example  occurring  in  a  girl  of  sixteen,  from  whom  Sir  "William 
Fergusson  successfully  removed  a  growth  of  the  kind,  will 
be  found  in  the  Lancet,  July  26th,  1856. 

In  October,  1883,  I  had  under  my  care  in  University 
College  Hospital,  a  young  woman,  aged  twenty-five,  in  whom 
a  painless  enlargement  of  the  right  upper  jaw  had  been 
noticed  for  ten  years,  encroaching  upon  the  palate  and 
bulging  out  the  cheek.  I  successfully  removed  the  whole 
upper  jaw,  and  on  section  the  tumour  was  found  to  be 
simple  bone,  very  dense,  but  otherwise  healthy.  One  half  of 
the  specimen  is  in  University  College  and  the  other  in  the 
College  of  Surgeons'  Museums. 

In  the  Museum  of  Charing  Cross  Hospital  is  a  remarkable 
specimen  of  osseous  tumour  of  the  upper  jaw,  removed  by 
Mr.  Hancock,  The  whole  jaw  seems  expanded  anteriorly,, 
and  the  outer  compact  plate  is  perfect,  except  at  the  part 
immediately  below  the  infra-orbital  foramen,  where  it  ha& 
given  way,  and  the  cancellous  structure  forming  the  interior 
of  the  tumour  is  seen.  Mr.  Hancock,  in  referring  to  this 
specimen  (Zawce^,  Jan.  13th,  1855),  specially  calls  attention 
to  the  fact  that  the  bone  yielded  to  pressure  to  such  an  extent 
as  to  lead  to  some  doubt  as  to  its  osseous  nature. 

A  still  more  remarkable  specimen  of  the  same  kind  i& 
preserved  in  the  Musee  Dupuytren  at  Paris,  which  is  shown 
in  Figs.  119  and  120  from  the  Trait6  de  Pathologic 
Exteriu,  by  M.  Vidal  de  Cassis.  It  is  connected  with  the 
left  superior  maxilla,  being  limited  internally  by  the  inter- 
maxillary suture,  behind  by  the  pterygoid  process,  above  and 
externally  by  the  malar  bone.  The  tumour  encroaches  con- 
siderably upon  the  cavity  of  the  mouth  and  reaches  back  as 


OSTEOMA    OF   THE    UPPER    JAW. 


273 


far  as  the  front  of  the  spine.  Its  form  is  bi-lobecl,  and  in 
the  deep  sulcus  between  the  lobes  can  be  seen  a  molar  tooth. 
All  the  other  teeth  of  the  jaw  have  disappeared,  and  there  is 
no  trace  of  their  alveoli.  The  left  orbit  and  nasal  fossa  are 
not  sensibly  diminished  in  size,  but  the  cavity  of  the  mouth 
is  almost  entirely  occupied  by  the  posterior  lobe  of  the 
tumour.  The  lower  jaw  has,  in  this  case,  undergone  several 
remarkable  alterations.  It  must  at  first  have  pressed  upon 
the  growth  and  produced  the  deep  sulcus  between  the  lobes, 
but  in  its  turn  the  tumour  has  reacted  upon  the  lower  jaw 
with  the  following  effect :  It  has  caused  a  double   luxation 


Fig.  119. 


Fig.  120. 


of  the  jaw,  the  left  condyle  resting  against  the  root  of  the 
zygoma  and  the  glenoid  cavity  being  filled  with  soft  material. 
The  teeth  of  the  left  side  of  the  lower  jaw  have  disappeared, 
and  absorption  of  part  of  the  coronoid  process  and  the  whole 
of  the  alveolus  has  taken  place,  so  that  only  the  base  of  this 
part  of  the  bone  is  left.  The  outer  surface  of  the  tumour  is 
smooth,  and  presents  numerous  vascular  grooves  of  good  size  ;. 
at  many  points  it  is  perforated  with  holes.  The  vascularity 
of  the  other  bones  of  the  face  does  not  appear  augmented. 

In  the  Museum  of  ISTetley  Hospital,  which  includes  the 
preparations  formerly  at  Fort  Pitt,  Chatham,  there  is  a 
specimen  of  large  osseous  tumour  of  the  upper  jaw  closely 
resembling  that  last  described,  but  of  smaller  size. 

s 


274         NON-MALIGNANT    TUMOURS    OF    THE    UPPER    JAW. 

Besides  this  form  of  bony  tumour,  due  apparently  to  an 
increase  of  the  cancellous  structure  of  the  bone,  specimens 
of  tumour  as  hard  as  ivory  have  from  time  to  time  been 
met  with.  Perhaps  the  most  remarkable  of  these  is  one 
described  by  Mr.  Hilton,  in  the  Ghiys  Hospital  Beports, 
vol.  i,  p.  493,  from  the  fact  that  the  tumour  separated 
spontaneously  from  the  face.  The  patient  was  a  man  aged 
thirty-six,  who,  twenty-three  years  before  Mr,  Hilton  saw 
him,  noticed  a  pimple  below  the  left  eye,  close  to  the  nose, 
which  he  irritated,  and  from  that  spot  the  tumour  appears 
to  have  originated.  The  tumour  in  its  growth  displaced  the 
eyeball,  giving  rise  to  excruciating  pain,  which  subsided  on 
the  bursting  of  the  ball.  It  began  to  loosen  by  a  process 
of  ulceration  around  its  margin  six  years  before  it  fell  out, 
which  event  was  unattended  by  either  bleeding  or  pain. 
The  tumour  weighed  14!  ounces.  It  was  tuberculated 
externally,  and  an  irregular  cavity  existed  at  the  posterior 
part.  A  section  presented  a  very  hard  polished  surface 
resembling  ivory,  and  exhibited  lines  in  concentric  curves 
enlarging  as  they  were  traced  from  the  posterior  part.  The 
huge  cavity  left  by  the  tumour  was  bounded  below  by  the 
floor  of  the  nose  and  antrum,  above  by  the  frontal  and 
ethmoid  bones,  internally  by  the  septum  nasi,  and  externally 
by  the  orbit,  which  had  been  considerably  encroached  upon 
by  the  tumour.  This  patient  was  alive  in  1865,  thirty 
years  after  the  prolapse  of  the  tumour. 

A  case  in  many  respects  resembling  Mr.  Hilton's  case 
was  under  the  care  of  Sir  William  Fergusson,  whom  I  had 
the  opportunity  of  seeing  operate  upon  it.  The  patient  was 
a  young  man  of  twenty-one,  who  had  first  noticed  the 
swelling  on  the  left  side  of  the  face  twelve  years  before. 
It  grew  for  six  or  seven  years,  and  then  remained  stationary. 
Two  years  before  he  had  consulted  a  quack,  who  attempted 
to  destroy  the  growth  with  caustic,  and  produced  the  large 
hole  seen  in  the  lower  part  of  the  tumour  (Fig.  121). 

On  admission  into  King's  College  Hospital  there  was  a 
swelling  on  the  left  side  of  the  face  about  the  size,  of  a 
large  apple,  extending  from  the  eyebrow  to  a  line  less  than 


OSTEOMA    OF    THE    UPPER    JAW.  275 

one  inch  above  the  mouth.  Internally,  it  encroached  upon 
the  nose,  displacing  it  a  little,  the  nasal  bone  being  pushed 
forwards  and  the  left  ala  flattened  on  the  columna  ;  the  mass 
was  felt  by  the  finger  in  the  mouth  above  the  gums.  The 
nostril  on  the  same  side  was  perfectly  blocked  up,  the  patient 
being  totally  unable  to  breathe  through  it.  The  right  nostril, 
however,  was  quite  free.  Outwards,  the  tumour  extended 
to  the  angle  of  the  orbit ;  the  arch  was,  however,  not  dis- 
placed, but  the  tumour  extended   slightly  above   it.      The 

Fig.  121. 


floor  of  the  orbit  seemed  displaced.  The  eyeball  was  seen 
imbedded  in  the  most  prominent  and  central  part  of  the 
tumour,  and  removed  more  than  an  inch  from  its  natural 
position  in  the  orbit,  which  was  entirely  blocked  up  by  the 
mass.  There  was  no  extension  into  the  pharynx.  The  tumour 
was  everywhere  hard,  with  a  slight  blush  over  the  surface. 
In  its  centre  was  a  round  opening,  produced  by  the  caustic 
applied  two  years  previously,  of  about  the  size  of  a  shilling, 
deep,  and  displaying  in  its  floor  black  necrosed  bone,  and 
discharging  pus.  The  patient  said  he  had  suffered  neither 
headache  nor  pain  in  the  tumour  since  its  commencement, 
twelve  years  before,  and  that  his  sight  had  been  unaffected. 


276        NON-MALIGNANT    TUMOUES    OF    THE    UPPER   JAW. 

Sir  William  Eergusson  operated  upon  this  patient  on 
November  30th,  1867,  and  succeeded  in  removing  the  whole 
of  the  prominent  tumour,  weighing  loj  ounces,  which  con- 
sisted in  all  its  anterior  part  of  nodulated  bone  as  hard  as 
ivory,  and  posteriorly,  of  very  dense  ordinary  bone  mixed 
with  a  small  amount  of  cartilage.  A  section  showed  an 
ivory -like  mass  closely  resembling  Mr.  Hilton's  specimen, 
connected  with  a  mass  of  very  much  condensed  bone.  The 
tumour  sprang  apparently,  as  in  the  former  case,  from  the 
upper  part  of  the  maxilla,  and  had  invaded  the  antrum, 
orbit,  and  nostril.  The  palate  was  in  no  way  involved  in 
the  growth,  and  was  preserved  entire  at  the  operation,  Sir 
William  Fergusson  sawing  horizontally  immediately  above 
it.  Unfortunately  the  patient  sank  rather  suddenly,  from 
inflammation  of  the  lungs,  on  the  fourth  day. 

At  the  post-mortem  examination,  after  removal  of  the 
brain,  it  was  found  that  the  affection  of  the  bone  involved 
the  base  of  the  skull,  there  being  a  projection  of  the  size  of 
a  hazel-nut  from  the  sphenoid  near  the  optic  foramen.  This 
involved  the  foramen  and  extended  along  the  sphenoidal 
fissure,  the  optic,  third,  and  fourth  nerves  passing  through 
the  condensed  bone  of  which  it  was  composed.  The  brain 
was  unaffected  (vide  Lancet,  February  8th,  1868). 

This  specimen  was  exhibited  to  the  Pathological  Society 
of  London,  and  was  reported  upon  by  a  committee.  The 
report  of  this  committee,  drawn  up  by  Mr.  Hulke,  which 
will  be  found  in  extenso  in  vol.  xix  of  the  Pathological 
Transactions,  expresses  an  opinion  that  "  the  hard  part  of 
the  tumour  has  been  directly  formed  by  the  exogenous 
growth  of  successive  layers  of  dense  bony  tissue  under  the 
periosteum,  which  opinion  is  confirmed  by  the  absence  from 
the  hard  tissue  of  the  regular  Haversian  systems  so  charac- 
teristic of  secondary  bone." 

In  both  these  cases  the  tumour  appears  to  have  taken  its 
origin  in  the  upper  wall  of  the  antrum  and  to  have  grown 
forwards  ;  but  tumours  of  the  same  kind  have  been  found 
completely  within  the  superior  maxilla,  the  anterior  wall  of 
which  has  been  merely  expanded  by   the  growth  behind  it. 


OSTEOMA    OF    THE    UPPER    JAW.  277 

Of  this,  two  cases  reported  within  the  last  few  years  by 
M.  Michon  and  Dr.  Duka  are  good  examples,  and  they  will 
be  elucidated  by  reference  to  a  case  recorded  by  M. 
Demarquay. 

M.  Michon's  case  is  reported  in  the  second  volume  of  the 
M6moires  de  la  SocieU  de  Chirurgic  de  Paris  ( 1 8  5  i ) ;  his 
patient  being  a  man  of  nineteen,  who  had  a  large  tumour 
of  the  right  upper  jaw,  which  had  existed  for  three  years. 
The  tumour  was  rounded  and  hard,  and  had  pushed  up  the 
eyeball  considerably,  and  closed  the  right  nostril,  but  the 
palate  was  not  affected.  M.  Michon  operated  in  January, 
1850,  by  turning  up  a  triangular  flap  of  skin.  He  had 
intended  to  have  removed  the  entire  upper  jaw,  but  having 
with  considerable  difficulty  removed  the  front  wall  of  the 
antrum,  he  found  the  tumour  lying  in  the  cavity,  and  con- 
nected only  with  the  floor  of  the  orbit  and  the  vomer.  After 
an  operation  extending  over  an  hour  and  six  minutes,  and 
without  auEesthetics,  the  tumour  was  at  length  removed. 
The  whole  of  the  vomer  and  a  part  of  the  maxilla  came 
away  with  the  tumour,  which  was  a  flattened  sphere,  or 
somewhat  resembled  a  heart  in  shape.  It  weighed  120 
grammes  (1800  grains),  and  was  deeply  lobulated,  particu- 
larly on  the  posterior  aspect.  A  section  showed  concentric 
markings  upon  a  surface  of  ivory,  and  microscopic  examina- 
tion demonstrated  the  lacunae  and  canaliculi  of  true  bone. 
The  patient  made  a  good  recovery. 

Dr.  Duka's  case  is  reported  in  the  Pathological  Society's 
Transactions,  vol.  xvii,  and  occurred  in  a  female  native  of 
Bengal,  aged  twenty-six,  and  on  the  right  side  of  the  face, 
which  was  not  much  deformed.  There  was  a  discharge  from 
the  right  nostril,  which  was  obstructed,  and  on  examination 
a  hard  tumour  was  found  within  it,  which  tuas  movahle,  but 
could  not  be  extracted,  and  which  had  existed  six  years. 

Dr.  Duka,  failing  to  extract  the  tumour  by  laying  open 
the  nostril,  resorted  to  the  somewhat  unusual  proceeding  of 
cutting  a  wedge  out  of  the  hard  palate,  and  thus,  after  an 
operation  of  three-quarters  of  an  hour,  without  chloroform, 
succeeded  in  removing  the  growth.      The  patient  recoverexl 


278         NON-MALIGNANT    TUMOUES    OF    THE    UPPER   JAW. 

The  tumour  is  preserved  in  St.  George's  Hospital  Museuni, 
and  is  figured  in  the  Panwlogical  Transactions,  from  which 
the  accompanying  illustration  (Fig.  122)  is,  by  permission, 
taken.  It  has  an  oblong  shape,  and  is  not  unlike  a  middle- 
sized  potato,  with  depressions  and  elevations  passing  irregu- 
larly over  it.  The  upper  part,  which  is  believed  to  have 
been  in  contact  with  the  cribriform  plate  of  the  ethmoid 
bone,  exhibits  corresponding  delicate  depressions,  with  other 
deeper  sulci  in  front,  behind,  and  on  the  sides,  probably  for 
the  passage  of  blood-vessels.     At  the  lower  surface  is  a  large 

Fig.  122. 


nipple-like  process,  smooth  throughout.  This  lay  in  contact 
with  the  palatine  process,  and  it  has  the  same  dark  appear- 
ance as  the  anterior  part  of  the  body,  which  presented  at  the 
nostril.  At  the  base  of  this  process  is  a  large  hole  piercing 
it  quite  through,  and  allowing  the  tip  of  the  little  finger  to 
enter  it.  In  this  lacuna  was  a  polypoid  mass  which  con- 
tained a  nucleus  of  cartilage,  round  and  flat  like  a  small-sized 
lentil.  It  was  this  nipple-like  prominence  impinging  upon 
the  nasal  process  which  prevented  the  removal  of  the 
tumour,  without  interfering  with  the  superior  maxillary  bone. 
The  whole  bony  mass,  which  is  of  a  compact  ivory-like 
character,  weighs  1060  grains:  its  long  diameter  is  nearly 
three  inches,  the  short  one  an  inch  and   two  lines,  and  the 


OSTEOMA    OF    THE    UPPEE    JAW.  279 

longest  circumfereuce  seven  inches.  The  microscope  gives 
evidence  of  structure  closely  resembling  that  of  M.  Michon's 
tumour.  There  are  no  distinct  Haversian  systems,  but 
abundance  of  lacunse  arranged  around  vascular  canals.  In 
some  parts  of  the  tumour  the  characters  are  very  much  those 
of  simple  ossified  cartilage,  clusters  of  large  ossified  cells 
being  packed  closely  together. 

This  case  is  remarkable  from  the  fact  that  the  attachment 
of  the  tumour  had  given  way,  and  that  it  was  therefore 
loose  in  the  antrum.  It  would  have  appeared  to  be  unique 
in  this  particular,  but  for  the  publication  in  the  Gazette. 
MMicale  cle  Earis  (April  20th,  1867),  of  a  very  similar  case 
of  non-adherent  exostosis,  or  osteoid  tumour,  by  M.  Demar- 
quay,  of  which  the  following  are  the  leading  features : 

A  gentleman,  aged  fifty-three,  in  good  health,  but  the 
subject  of  syphilis,  had  a  swelling  of  the  left  side  of  the  face, 
which  had  existed  for  twenty  years.  It  gave  no  incon- 
venience except  the  disfigurement,  until  six  months  before  he 
applied  to  M.  Demarquay,  when  an  abscess  formed  and 
burst,  leaving  a  fistula.  After  this  neuralgia  came  on,  and 
other  abscesses  formed,  rendering  the  face  swollen  and  red. 
On  examination  several  fistulge  were  found  both  within  and 
without  the  mouth.  There  was  evidently  suppuration 
within  the  antrum,  probably  due  to  a  sequestrum. 

At  the  operation,  on  Jan.  4th,  1867,  it  was  found  impos- 
sible to  extract  the  sequestrum,  and  M.  Demarquay  there- 
fore removed  the  entire  maxilla,  and  the  patient  recovered. 

The  jaw  showed  an  increase  of  size  and  density ;  the  front 
wall  of  the  sinus  was  thrown  forward,  so  as  to  present  the 
segment  of  a  sphere,  and  was  thickened  so  that  its  resistance 
was  increased.  The  posterior  part  was  also  enlarged,  and 
had  projections  upon  it,  one  of  which  also  pushed  up  the 
floor  of  the  orbit.  There  were  numerous  sinuses  in  various 
parts,  through  which  pus  escaped. 

On  section,  a  white  osteo-cartilaginous  substance  was 
found  filling  up  the  whole  cavity  of  the  antrum,  but  not  at- 
tached to  its  walls.  In  some  parts  this  was  of  a  more  fibrous 
character,  whilst  in  others  it  was  dense  bone.     In  the  centre 


280         NON-MALIGNANT  TUMOUKS   OF    THE    UPPER   JAW. 

was  a  large  fragment  of  bone,  of  a  blackish  colour,  and  closely 
resembling  a  sequestrum.  This  was  surrounded  by  some 
smaller  portions,  and  by  a  cavity  containing  a  quantity  of 
pus,  into  which  the  sinuses  could  be  traced.  It  was  impos- 
sible to  tell  from  which  part  of  the  wall  the  tumour  had 
sprung. 

Considerable  difference  of  opinion  exists  concerning  the 
pathology  of  these  tumours.  It  has  been  suggested  that  they 
are  formed  by  the  ossification  of  an  enchondroma.  In  no 
case,  however,  have  typical  cartilage  cells  been  found  in  any 
stage  of  the  growth  of  an  osteoma.  Other  observers  look 
upon  them  as  outgrowths  from  the  bone,  as  exostoses,  in 
fact.  The  fact  that  the  connection  between  the  tumour  and 
the  bone  is  so  slight  or  may  even  be  absent  militates  against 
this  view.  The  microscopical  structure  of  these  growths 
again  is  not  like  that  of  exostoses. 

It  has  been  suggested  that  osteomata  found  in  the  antrum 
originate  in  the  muco-periosteal  lining,  by  the  cells  of  the 
periosteum  depositing  calcareous  salts  in  the  mucous  mem- 
brane, or  in  the  fibrous  odontomata  of  Broca. 

In  the  absence  of  sufficient  evidence  it  is  impossible  to 
give  the  preference  to  any  one  of  these  views,  and  for  the 
present  the  question  must  be  considered  an  open  one. 


CHAPTEE    XVII. 

MALIGNANT    TUMOUKS    OF    THE    UPPER   JAW. 

Sarcoma  and  Carcinoma. 

According  to  the  statistics  of  0.  Weber,  carcinoma  of  the 
upper  jaw  is  much  more  frequent  than  sarcoma.  In  the 
great  majority  of  cases  collected  by  him  the  diagnosis  was 
made  by  the  naked  eye  and  not  by  the  microscope,  and  this 
fact  is  sufficient  to  invalidate  his  conclusions  upon  this 
point.  Surgeons  at  the  present  day  are  unanimous  in  their 
opinion  that  the  upper  jaw  is  more  often  the  site  of  sarcoma 
than  of  carcinoma. 

I.  Sarcoma. — This  is  the  only  malignant  growth  which 
commences  in  the  jaw  itself.  The  other  malignant  tumours, 
the  carcinomata,  originate  in  some  neighbouring  epithelial 
structure,  and  secondarily  invade  the  bone.  It  is  usual,  in 
dealing  with  sarcomata,  to  divide  them  into  two  main  groups  ; 
those  originating  in  the  bone  itself,  the  central  sarcomata, 
and  those  originating  in  the  periosteum,  the  peripheral  or 
periosteal  sarcomata. 

(a)  The  Central  Sarcomata. — These  originate  in  the  in- 
terior of  the  bone,  and  in  the  great  majority  of  cases  present 
the  structure  of  myeloid  sarcoma.  In  a  few  cases  the  mye- 
loid structure  may  be  absent  or  may  be  largely  replaced  by 
round  or  oval  cells,  in  which  case  it  is  called  a  round-celled 
sarcoma.  When  the  myeloid  sarcoma  is  situated  in  the 
alveolar  portion  of  the  jaw,  it  is  called  a  myeloid  cimlis,  and 
this  has  already  been  described  in  the  chapter  on  Diseases 
of  the  Gums  (p.  236). 

The  diagnosis  of  myeloid  sarcoma  in  the  upper  jaw,  in 


282  MALIGNANT    TUMOUES    OF    THE    UPPER    JAW. 

situations  other  than  the  alveolar  process,  is  by  no  means  easy. 
The  bone  is  slowly  expanded,  much  as  it  would  be  by  a 
cyst,  or  by  any  benign  tumour.  If  the  disease  originate  on 
the  exterior  of  the  bone,  or,  when  springing  from  the  interior, 
if  sufficient  absorption  of  the  bone  have  taken  place  to  allow 
the  tumour  to  appear  beneath  the  mucous  membrane,  the 
characteristic  dark  maroon  colour  of  the  tumour  may  be 
perceived.  Cysts  occasionally  form  in  the  substance  of  a 
myeloid  tumour,  and  an  exploratory  puncture  of  these  may 
yield  fluid  in  which  the  characteristic  myeloid  cells  may  be 
discovered  microscopically. 

Myeloid  disease  occurs  mostly  before  the  age  of  twenty- 
five.  Sir  J.  Paget  ("Surgical  Pathology,"  p.  524)  quotes 
two  cases  of  Sir  William  Lawrence's,  occurring  in  the  upper 
jaws  of  women  of  twenty-one  and  twenty-two  years  of  age, 
the  latter  of  which  illustrates  extremely  well  the  recurrence  of 
myeloid  growths  (of  which  there  can  be  no  question),  and 
also  the  very  curious  fact  that  a  tumour  on  the  opposite 
side  to  that  removed,  and  which  presented  appearances 
exactly  corresponding  to  it,  spontaneously  subsided.  The 
specimen  is  in  St,  Bartholomew's  Hospital  Museum. 

Pig.  123  shows  a  patient  from  whom  Mr.  Canton  removed 
a  myeloid  tumour  in  1864.  She  was  thirty-five  years  old, 
and  the  tumour  appeared  to  have  followed  a  blow.  It  had 
been  twice  removed  before  she  came  under  Mr.  Canton's 
care,  and  that  gentleman  successfully  removed  the  left 
superior  maxilla  with  the  tumour,  a  portion  of  which  hung 
down  into  the  pharynx.  The  tumour  was  brought  before 
the  Pathological  Society  of  London,  in  December,  1865,  ^^^ 
the  following  is  a  description  of  the  tumour,  by  Messrs. 
Bryant  and  Adams,  to  whom  the  specimen  was  referred  : 
"  The  parts  placed  in  our  hands  for  examination  consisted  of 
the  left  superior  maxillary  bone,  including  its  orbital  plate, 
from  the  inferior  surface  of  which  appeared  to  grow  a  large 
tumour,  which  filled  the  cavity  of  the  antrum,  and  projected 
forwards  and  inwards  into  the  nasal  cavity.  There  was  also 
a  second  and  loose  portion,  the  size  of  a  walnut,  which 
appeared  to  have  been  broken  off  during  the  operation,  and 


MYELOID    SAKCOMA    OF    THE    UPI'ER    JAW. 


28: 


was  said  to  have  projected  posteriorly  towards  the  pharynx. 
The  external  wall  of  the  antrum  was  not  expanded  so  fully 
as  is  usually  found  in  tumours  of  the  antrum.  The  tumour, 
which  had  been  some  time  in  spirit,  was  of  a  firm  fibrous 
nature  and  irregularly  lobulated,  and  it  had  a  dense  capsule. 

Fig.  123. 


On  section,  the  structure  presented  a  large  amount  of 
fibrous  tissue,  arranged  in  a  curvilinear  form,  intermixed 
with  other  tissue  not  easily  broken  up.  Microscopically 
examined,  the  tumour  consisted  of  an  abundance  of  fibrous 
tissue,  which  formed  the  stroma,  containing  in  its  meshes 
innumerable  cells,  generally  of  a  circular  or  ovoid  form, 
varying  from  two  to  three  diameters  of  a  blood-corpuscle, 
and  some  of  a  still  larger  size.  The  cells  were  all  nucleated, 
usually  containing  several  nuclei,  and  frequently  presenting 


284  MALIGNANT    TUMOUES    OF   THE    UPPER   JAW. 

a  granular  appearance.  Large  compound  cells  were  abun- 
dant in  the  posterior  and  softer  lobe  of  the  tumour,  and  a 
few  elongated  cells  were  seen  amongst  the  fibrous  tissue. 
These  large  compound  cells  presented  very  much  the  ap- 
pearance of  the  poly-nucleated  cells  met  with  in  myeloid 
tumours." — Transactions  of  the  Patlwlogieal  Society,  vol.  xvii. 

The  subsequent  history  of  this  patient  is  given  as  follows 
in  the  Lancet  of  January  26th,  1872,  and  it  is  remarkable 
that  the  tumour  on  one  side  should  have  had  a  character 
differing  from  that  on  the  other :  "  In  June,  1871,  she  again 
presented  herself  at  the  Charing  Cross  Hospital  with  a  large 
tumour  filling  up  the  antrum  of  the  right  upper  maxilla, 
and  extending  forwards,  causing  a  projection  of  the  upper 
lip.  Mr.  Canton  accordingly  removed  the  remaining  upper 
maxilla.  The  operation  was  perfectly  successful,  and  pre- 
sented in  itself  no  points  of  particular  interest.  The  edges 
of  the  incision  were  brought  together  with  silver  sutures, 
and  no  dressing  of  any  kind  was  used,  the  mouth  being 
simply  kept  perfectly  clean  and  sweet  by  the  frequent  use 
of  Condy^s  fluid.  Within  a  week  of  the  operation  she  left 
her  bed,  and  within  three  weeks  she  was  discharged  from 
the  hospital.  Five  months  later  the  patient  wrote  to  say 
that  she  had  enjoyed  perfect  health  since  she  had  left  the 
hospital.  On  microscopic  examination  the  tumour  proved 
to  be  simply  fibrous.  It  had  been  growing  for  a  year 
before  removal.  Notwithstanding  that  a  great  part  of  the 
framework  of  the  face  had  been  taken  away,  and  that  a 
portion  of  the  orbital  plate  was  removed  at  both  operations, 
there  was  remarkably  little  deformity  of  the  face.  The 
patient  had  lost  all  power  of  muscular  expression,  but 
beyond  this  there  was  nothing  to  attract  attention,  except  a 
slight  falling  in  of  the  upper  lip  on  the  right  side.  There  was 
no  falling  in  of  the  nose,  the  raphe  of  what  was  the  roof 
of  the  mouth  deriving  great  support  from  a  firm  pseudo- 
palate,  which  had  formed  of  cicatricial  tissue  after  the  first 
operation.  The  cicatrices  of  the  incisions  were  scarcely 
noticeable,  as  they  followed  the  natural  lines  of  the  face." 

Mr.  Canton  also  obliged  me  with  the  portrait  and  history 


MYELOID    SARCOMA    OF   THE    UPPEE  JAW.  285 

of  a  case  of  still  more  marked  myeloid  disease  of  the  upper 
jaw,  wliicli  was  also  under  his  care.  The  patient  was  forty- 
six  years  of  age,  which  is  decidedly  advanced  for  the  disease, 
and  the  tumour  grew  with  unusual  rapidity.  Mr.  Canton 
removed  the  jaw  in  Dec.  1866,  and  I  had  the  opportunity  of 
seeing  the  patient  in  Jan.  1867,  when  he  was  quite  well,  but 
had  still  a  small  fistulous  opening  on  the  face.  Dr.  Tonge 
carefully  examined  the  tumour  (which  is  preserved  in  the 
Museum  of  Charing  Cross  Hospital),  and  has  kindly  fur- 
nished me  with  the  following  report  upon  it  and  upon  the 
microscopic  appearances  it  presented  :  "  The  tumour  was 
about  the  size  and  shape  of  a  large  hen's  egg  that  had  been 
flattened  slightly  in  the  transverse  direction,  and  measured 
(after  being  in  moderately  strong  spirit  for  some  days)  about 
two  and  three-quarter  inches  in  length,  from  one  and  three- 
quarters  to  two  inches  transversely,  and  about  one  and  a 
half  inch  in  thickness.  It  was  of  firm  consistence  through- 
out, and  on  section  presented  a  whitish  appearance,  with 
a  small  pink  patch  or  two,  and  a  whitish,  creamy-looking 
juice  could  be  scraped  from  the  cut  surface.  The  micro- 
scopical appearances  of  a  portion  of  a  thin  section  of  the 
tumour,  that  had  been  preserved  in  glycerine  and  coloured 
with  carmine,  are  represented  in  the  accompanying  drawing, 
which  was  taken  with  the  aid  of  the  camera  lucida.  The 
fibrous  element  was  much  less  abundant  than  the  cellular, 
and  consisted  of  white  fibrous  tissue,  with  numerous  fine 
curling  fibres  of  yellow  elastic  tissue,  and  many  small  oval 
and  rounded  nuclei  were  imbedded  in  the  fibrous  structure. 
The  greater  portion  of  the  tumour  seemed  to  be  composed 
of  cells.  These  were  mostly  of  an  irregularly-rounded  form, 
often  with  pointed  processes,  and  some  shuttle-shaped  and 
spindle-shaped,  of  a  somewhat  trapezoidal  form,  were  not 
uncommon,  while  a  few  cells  presented  the  character  of 
those  distinctive  of  myeloid  tumours.  All  the  cells  con- 
tained one,  and  often  two,  very  large  and  generally  oval 
nuclei,  with  one,  two,  or  three  nucleoli,  and  a  variable 
number  of  oil  globules.  The  myeloid  cells  observed  were  of 
irregular  outline,  and  contained  from  three  to  five  nuclei, 


286  MALIGNANT  TUMOURS    OF    THE    UPPER  JAW. 

with  single  or  double  nucleoli — one  very  large  cell  con- 
tained six  nuclei. 

"  These  cells  were  not  very  numerous,  but  appeared  suffi- 
ciently so  to  justify  the  application  of '  myeloid '  to  the  tumour, 
though,  to  the  naked  eye,  and  on  a  superficial  microscopical 
examination,  it  presented  many  of  the  appearances  of  cancer.'^ 

In  the  Museum  of  the  College  of  Surgeons  are  two  speci- 
mens consisting  of  the  two  superior  maxillse  of  a  woman, 
aged  twenty-one,  which  were  given  me  by  Messrs.  Andrews 
and  Coates,  of  Salisbury,  who  removed  them.  The  left  upper 
jaw  has  been  macerated,  showing  a  calcified  tumour  springing 
from  the  anterior  part ;  the  right  jaw  has  a  growth  involv- 
ing the  anterior  portion  and  extending  into  the  nasal  fossa. 
The  growth  in  these  cases  was  regarded  by  the  operators  as 
an  example  of  scirrhus,  but  I  am  enabled  by  the  kindness  of 
Dr.  Lush,  of  "Weymouth,  to  correct  this  statement,  by  a  record 
which  he  has  of  the  microscopic  details  observed  when 
the  tumours  were  recent,  as  follows  :  "  A  section  show  sd 
numerous  spheroidal  cells  with  one,  two,  or  more  nuclei, 
free  matter  and  some  compound  cells."  The  tumour  should 
therefore  doubtless  properly  be  regarded  as  myeloid. 

The  history  of  the  patient  is  the  following  :  Jane  F., 
aged  twenty-one,  was  admitted  into  the  Salisbury  Inj&rmary, 
July  24th,  1858,  for  a  tumour  of  the  left  upper  jaw. 
The  operation  of  removal  of  the  left  upper  jaw  was  per- 
formed by  Mr.  Andrews,  and  she  was  made  an  out-patient 
Aug.  28th,  1858.  She  was  readmitted  on  Oct.  1st,  1859, 
under  Mr.  Coates,  having  a  fortnight  before  perceived  a  small 
growth  occupying  the  edge  of  the  alveolar  process  at  the  site 
of  the  left  upper  incisor,  which  became  rapidly  exquisitively 
painful,  and  involved  the  alveolus  of  the  right  side,  and  also  the 
upper  lip.  Mr.  Coates  removed  the  remaining  right  superior 
maxilla  under  chloroform,  Oct.  13th,  1859.  The  portion  of 
the  lip  covering  the  small  tumour  (which  was  about  the  size 
of  a  hazel-nut)  was  also  removed,  and  found  to  be  infiltrated 
with  disease.  The  patient  was  discharged  cured  Nov.  5  th, 
1859,  ^^d  was  in  perfect  health  in  1866. 

Vascular    tumours,  closely    resembling  erectile    tumours 


VASCULAR    SARCOMA    OF    THE    UPPER    JAW.  287 

in  other  parts  of  the  body,  have  been  occasionally  met  with 
in  the  upper  jaw. 

There  is  no  doubt  that  the  great  majority  of  pulsating 
tumours  of  bone  are  examples  of  very  vascular  sarcomata, 
and  the  question  naturally  arises  whether  certain  vascular 
tumours,  met  with  in  the  upper  jaw,  which  have  hitherto 
been  regarded  as  non-malignant,  ought  not  to  be  classed 
among  the  sarcomata. 

It  must  be  remembered  that  these  vascular  growths  of 
the  upper  jaw  were  described  many  years  ago,  before  the 
methods  of  diagnosis  employed  at  the  present  day  were 
available.  Of  recent  years  no  such  growths  have  been  met 
with,  or  if  they  have,  they  have  been  regarded  as  vascular 
sarcomata. 

Mr.  Listen,  in  1841,  successfully  removed  a  specimen  of 
the  kind,  which  is  preserved  in  University  College,  from  a 
young  man,  aged  twenty-one.  The  tumour  was  of  more 
than  three  years'  growth,  and  projected  into  the  nares  and 
pharynx,  forming  a  tumour  beneath  the  cheek ;  but  the 
preparation  shows  that  the  alveolus  and  all  the  lower  and 
anterior  part  of  the  maxilla  were  not  involved  in  the  disease. 
The  tumour  was  not  painful,  but  frequent  hsemorrhages 
had  taken  place  from  its  surface.  The  case  will  be  found 
in  the  Lancet,  Oct.  9th,  1 84 1.  Mr.  Liston  removed  the  jaw, 
cutting  completely  beyond  the  disease,  and  remarks  con- 
cerning it  (Lancet,  Oct.  26th,  1844)  :  "It  was  a  curious- 
looking  tumour,  and  it  struck  me  that  it  was  of  a  fibrous 
character,  not  growing  from  the  jaw,  but  involving  it.  Mr. 
Marshall  some  months  afterwards  discovered  that  the  whole 

mass  was  erectile You  will  see  that  it  is  as  complete 

and  beautiful  a  specimen  of  an  erectile  tumour  as  any  that 
I  have  yet  shown  you." 

The  tumour,  which  is  in  the  Museum  of  University  Col- 
lege, is  described  as  follows  in  the  catalogue  by  Mr.  Marcus 
Beck :  "  A  large  tumour  of  the  pterygo-maxillary  fossa  re- 
moved with  the  upper  jaw.  The  specimen  includes  the  whole 
of  the  maxilla  except  a  narrow  strip  of  its  palatine  process, 
and    small    portions  of  the  nasal  and  malar  processes,  the 


288  MALIGNANT   TUMOURS    OF   THE   UPPEE    JAW, 

whole  of  the  lower  part  of  the  palate  bone,  and  the  lower 
portions  of  both  pterygoid  plates  of  the  sphenoid,  and  the 
inferior  turbinated  bone. 

"  The  tumour,  which  measures  about  three  inches  in  the 
antero-posterior  direction,  has  grown  from  the  posterior 
surface  of  the  maxilla,  and  filled  the  spheno-maxillary  and 
lower  part  of  the  temporal  fossae,  and  has  passed  far  back- 
wards under  cover  of  the  ramus  of  the  inferior  maxilla  so  as, 
on  the  inner  side,  to  have  projected  within  the  pharynx ; 
and  from  the  anterior  part  of  the  tumour  a  portion  has 
grown  forwards  beneath  the  hard  palate  into  the  mouth. 
The  posterior  half  of  the  tumour  is  deeply  cleft  into  lobes. 
On  the  inner  aspect  of  the  parts  a  piece  of  the  tumour  has 
been  cut  away  ;  the  divided  surface  has  a  uniformly  open, 
cavernous  structure,  like  that  of  the  corpus  spongiosum 
penis,  the  meshes  of  which  are  nowhere  occupied  by  a  solid 
substance,  and  probably  allowed  of  the  circulation  of  blood 
through  them.  The  tumour  is  everywhere  bounded  by  a 
dense  layer  of  fibrous  tissue.  The  cavity  of  the  antrum  is 
entirely  unaffected." 

M.  Gensoul  also  met  with  an  erectile  tumour  springing 
from  the  antrum,  in  one  of  the  cases  from  which  he  success- 
fully extirpated  the  upper  jaw. 

Mr.  Butcher,  of  Dublin,  has  described  ("  Operative  and 
Conservative  Surgery,"  p.  249)  a  case  of  successful  removal  of 
the  right  upper  jaw,  on  account  of  a  large  fibro-vascular 
tumour  springing  from  the  antrum  of  a  lad  of  sixteen.  Mne 
months  before  admission  he  had  had  a  polypoid  growth  re- 
moved from  the  nostril,  giving  rise  to  severe  hsemorrhage.  It 
reappeared  in  a  month,  and  increased,  so  that  when  he  came 
under  Mr.  Butcher's  care  there  was  considerable  deformity 
of  the  face,  and  the  nostril  was  filled  with  the  tumour,  which 
projected  behind  the  soft  palate.  After  the  boy  had  been 
in  hospital  a  few  days  the  tumour  suddenly  increased  with 
great  rapidity,  and  interfered  so  much  with  respiration  and 
deglutition  that  Mr.  Butcher  at  once  removed  the  jaw,  and 
the  patient  made  a  good  recovery. 

The    following  is  the  description  given  of  the    tumour  : 


VASCULAR  SAKCOMA  OF  THE  UrPER  JAW.      289 

"  The  structure  of  the  tumour  presented  many  interesting 
peculiarities.  Its  attachment  and  origin  sprang  from  the 
outer  part  of  the  autruni.  Not  only  was  it  incorporated 
with  the  lining  membrane,  but  it  likewise  implicated  tlie 
osseous  wall.  The  surface  from  which  it  sprang  in  the 
recent  state  was  softened,  vascular,  and  pulpy,  the  upper 
surface  of  the  tumour  was  lobulated  where  it  encroached 
upon  the  orbit,  and  elevated  its  floor  ;  the  lobules  were  of 
various  sizes — some  very  small,  but  each  consistent  in  struc- 
ture, and  invested  by  a  dense  capsule  in  a  similar  way  to  the 
larger  masses  of  the  growth.  The  entire  tumour  was  re- 
markable for  its  great  vascularity,  which  was  more  parti- 
cularly confined  to  the  posterior  and  upper  surface ;  while 
on  section  the  structure  was  dense  by  comparison,  pale, 
eminently  firm,  and  partaking  of  a  fibrous  matted  nature. 
This  integral  arrangement  was  very  manifest  under  close 
examination  with  the  microscope,  and  cleared  away  the  sus- 
picion which,  on  superficial  inspection,  might  have  been 
created  of  encephaloid  disease  being  the  synonym  most 
applicable  to  the  growth.  There  was  a  total  absence  of  all 
nucleated  cells,  either  globular,  caudate,  or  spindle-shaped ; 
and,  above  all,  the  section  of  any  part  only  yielded  a  minute 
quantity  of  serum  or  blood  on  pressure,  and  not  the  true 
succus  of  cancerous  tissue.  The  tumour,  though  destructive 
to  the  neighbouring  parts  by  pressure,  yet  did  not  appro- 
priate or  incorporate  them  in  its  structure.  .This  peculiarity 
of  non-malignant  growths  was  strikingly  manifest  in  the 
present  instance  ;  for,  by  pressure  producing  interstitial  ab- 
sorption, the  cancellated  structure  of  the  ethmoid  and  infe- 
rior spongy  bones  was  attenuated  and  removed  ;  and  by  the 
same  process  the  vomer  was  detached  from  its  position — a 
few  shreds  of  it  being  spared  and  hanging  loosely  on  the 
sinistral  surface  of  the  tumour.  The  vascularity  of  the 
growth,  though  remarkable  on  the  surface,  yet  did  not  per- 
meate its  texture ;  hence  a  tendency  to  degenerate  by 
assumed  depravity  of  action  was  lessened.  Again,  the  vas- 
cularity of  the  surface  will  readily  account  for  the  repeated 
and  profuse  losses  of  blood — a  point  of  great  practical  value 

T 


290  MALIGNANT    TUMOURS    OF   THE    UPPER    JAW. 

because  placing  the  surgeon  on  his  guard  as  to  the  import- 
ance which  should  be  attached  to  those  repeated  losses,  in 
constituting  a  diagnostic  feature  confirmatory  of  malignant 
disease." 

(b)  The  Periosteal  Sarcomata. — These  are  nearly  always 
either  spindle-celled  or  round-celled  sarcomata.  It  is  very 
rarely  that  a  myeloid  growth  originates  in  the  periosteum, 
but  they  have  been  met  with. 

The  Spindle-celled  Sarcoma  is  of  frequent  occurrence  in 
the  upper  jaw,  forming  many  of  the  specimens  formerly 
indiscriminately  named  "  osteo-sarcoma."  It  is  usually  of  a 
yellower  colour  than  the  fibrous  tumour  and  of  softer 
consistence,  and  on  section  it  exudes  a  serous  fluid.  The 
spindle-shaped  cells  are  often  of  great  length  and  size,  and 
each  cell  contains  one  or  more  oval  nuclei,  the  intercellular 
substance  being  homogeneous. 

Under  the  name  of  "  albuminous  sarcoma,"  Mr  Listen 
has  described  a  case  which  appears  to  be  of  this  kind,  in  the 
Lancet,  Nov.  26th,  1836,  which  proved  fatal  after  removal 
of  the  tumour.  The  patient  was  twenty-four  years  of  age, 
and  the  disease  appeared  to  have  originated  in  a  blow, 
and  grew  with  tolerable  rapidity.  The  tumour,  which  is 
preserved  in  the  College  of  Surgeons'  Museum,  is  oval 
in  form,  its  chief  diameters  being  about  three  inches  by  two 
inches,  and  contained  spaces  in  which  was  a  glairy  fluid, 
coagulable  by  heat.  Mr.  Lane  successfully  removed,  in  1 8  6 1 , 
both  upper  jaws,  together  with  the  vomer,  &c.,  which  were 
involved  in  an  "  albuminous  sarcoma,"  from  a  man,  aged 
forty-eight,  whose  case  will  be  found  in  the  Lancet,  Jan.  2  5  th, 
1862.  The  tumour  implicated  both  superior  maxillary  bones 
and  filled  both  nostrils.  It  formed  an  extensive  convex 
irregular  swelling  in  the  mouth,  which  pressed  down  the 
tongue.  Very  little  bony  material  could  be  distinguished 
in  the  position  of  the  palatine  processes  of  the  maxillary  or 
palate  bones,  and  the  growth  which  occupied  their  place  was 
soft  and  elastic,  and  was  ulcerated  in  two  or  three  spots,  of 
the  size  of  a  fourpenny-piece.  The  growth  first  showed 
itself  within  the  left  nostril  three  or  four  years  previously, 


SPINDLE-CELLED    SARCOMA    OF    THE    UPPER    J  AAV.        1^91 

presenting  the  appearance  of  a  nasal  polypus,  and  was 
removed  three  times. 

In  the  same  number  of  the  Laned  is  the  report  of  a  case 
of  tumour,  also  removed  by  Mr.  Lane,  from  a  child  of  nine 
years,  which  presented  much  the  same  characters.  The 
report  states  that  portions  of  the  growth,  placed  under  the 
microscope,  presented  the  characters  of  a  fibro-imcleated 
structure,  being  composed  of  minute  fibres,  in  which  wery 
disseminated  numerous  small  oval  nuclei  about  the  size  of 
blood  globules,  measuring  from  the  four-thousandth  to  the 
three-thousandth  part  of  an  inch  in  diameter. 

In  the  Lancet  for  August  31st,  1861,  is  the  report  of  a 
remarkable  case  of  fibro-cellular  tumour  of  the  jaw,  under 
the  care  of  Sir  William  Fergusson,  in  which  the  patient  was 
the  subject  of  two  tumours,  one  situated  in  the  right  cheek, 
the  other  in  the  antrum  and  roof  of  the  mouth.  The 
growths  were,  however,  perfectly  distinct  from  one  another, 
and  both  were  removed  at  a  single  operation,  which  was 
attended  with  the  best  results.  Sir  William  Fergusson  had 
seen  the  patient  twelve  months  before,  and  the  disease  then 
presented  so  malignant  an  aspect  that  he  dissuaded  her  from 
undergoing  any  operation.  Some  months  later,  the  disease 
in  the  mouth  was  found  to  be  an  ulcerated,  sloughy-looking 
mass,  and  the  finger  could  be  readily  passed  alongside  of  it 
into  the  antrum.  Perceiving  that  its  progress  had  been  slow, 
and  that  it  was  within  the  reach  of  surgical  aid,  he  thought 
he  would  give  her  a  chance  of  relief,  more  especially  as  there 
was  no  development  of  disease  in  any  other  situation,  and 
the  tumour  in  the  cheek  was  quite  distinct  from  that  in 
the  jaw. 

The  report  states  that  the  softer  part  of  the  disease 
appeared,  on  microscopical  examination,  to  consist  mainly  of 
a  fibro-granular  matrix,  containing  numerous  corpuscles, 
round,  regular,  of  uniform  size,  granular,  and  with  no  appear- 
ance of  nuclei.  The  much  firmer  tumour  of  the  cheek 
contained  corpuscles  of  a  similar  character,  with  a  large 
proportion  of  the  fibrous  element. 

The  tendency  to  ulceration  which  was  exhibited  in  this 


292  MALIGNANT    TUMOUKS    OF    THE    UPPER    JAW. 

case  is  a  marked  feature  of  this  form  of  disease,  and  not 
imfrequently  leads  to  difficulty  in  solving  the  question  of 
malignancy.  It  is  seldom  that,  in  the  case  of  the  upper  jaw,, 
the  skin  becomes  involved  in  the  disease,  but  in  the  lower 
jaw  this  frequently  happens,  and  large  fungous  protrusions 
occur  which  may  be  mistaken  foro]3en  cancer.  The  history 
of  the  case,  together  with  the  absence  of  any  enlargement 
of  the  lymphatic  glands,  is  sufficient  to  mark  the  nature  of 
the  growth. 

Ossification  frequently  takes  place  in  spindle-celled 
sarcomata,  and  when  this  is  the  case  the  terms  ossifying  or 
osteoid  sarcoma  or  osteosarcoma  oxe  often  employed. 

It  is  very  rare  for  fatty  degeneration  to  take  place  in 
sarcomata  ;  so  rare,  indeed,  that  it  is  not  mentioned  by 
most  authors. 

In  his  work  on  the  "Diseases  of  the  Bones"  (p.  283), 
Mr.  Stanley  mentions  "  fatty "  tumours  of  the  superior 
maxilla.  He  refers  (p.  104)  to  a  specimen  in  St.  Bartho- 
lomev/'s  Hospital  Museum,  of  which  the  following  is  the 
description  : 

"  Sections  of  a  tumour  which  occupied  the  situation  of  the 
superior  maxillary  bone,  and  was  removed  by  operation. 
The  whole  of  the  natural  structure  of  the  superior  maxillary 
bone  has  disappeared.  The  mucous  membrane  which  covered 
the  palatine  surface  of  the  bone  extends  over  a  part  of  the 
tumour.  The  morbid  growth  consists  of  a  moderately  firm 
fatty-looking  substance,  with  minute  cells  and  spicula  of  bone 
dispersed  through  it. 

"  From  a  man,  aged  forty-six.  The  disease  returned  after 
the  operation,  and  the  patient  died  in  consequence  of  haemor- 
rhage from  ulceration  of  the  internal  carotid  artery,  which 
became  involved  in  an  extension  of  the  disease." 

This,  as  far  as  can  be  judged,  would  appear  to  have  been 
an  example  of  spindle- celled  sarcoma  or  osteo-sarcoma,  which 
had  undergone  fatty  degeneration  ;  and  the  same  may,  I 
imagine,  be  said  of  the  cases  referred  to  by  Von  Siebold  as. 
osteo-steatomata. 

Chondrosarcoma,  in  which  spindle  or  round-celled  sarco- 


ROUND-CELLED    SARCOMA    OF    THE    UPPER   JAW.  29:> 

inatous  elements  are  mixed  with  the  cartilage  forming  the 
bulk  of  the  tumour,  occurs  occasionally  in  the  upper  jaw,  and 
is  apt  to  be  followed  by  secondary  deposits  in  the  lungs, 
this  clinical  fact  distinguishing  it  from  the  ordinary  enchon- 
droma.  In  1879,  I  was  consulted  respecting  a  young  lady 
who,  two  years  before,  liad  had  removed  from  the  floor  of 
the  orbit  a  small  growth  which  grew  from  the  orbital  plate 
and  displaced  the  eyeball.  The  growth  recurred,  and  when 
I  saw  the  patient  both  nostrils  were  completely  blocked  ; 
there  was  slight  bulging  of  the  antrum,  and  nobbly  swellings 
of  the  size  of  a  sixpence  on  the  raphe  of  the  hard  palate  on 
the  left  side,  and  another  on  the  right  side  of  the  palate. 
The  frontal  bone  also  seemed  affected.  I  advised  against  an 
operation,  but  another  surgeon  removed  the  upper  jaw,  and 
was  unable  to  take  away  the  whole  of  the  disease,  which 
proved  to  be  chondro-sarcoma. 

The  Bound-celled  Sarcoma,  medullary,  or  encephaloid 
sarcoma  is  of  frequent  occurrence  in  the  upper  jaw,  and 
from  its  vascularity  and  rapidity  of  growth  it  has  often  been 
mistaken  for  medullary  cancer,  which  in  its  clinical  history 
it  closely  resembles.  In  the  majority  of  cases  the  disease 
begins  in  the  antrum,  for  the  protruding  masses,  which  are 
found  in  the  nose  or  mouth,  are  but  secondary  to  a  formation 
within  that  cavity.  One  of  Mr.  Listen's  cases  is  conclusive 
on  the  point,  the  preparation  being  preserved  in  the  College 
of  Surgeons,  with  the  following  description :  "  The  greater 
part  of  a  left  superior  maxillary  bone,  with  a  tumour 
formed  in  the  antrum,  removed  by  operation.  The  tumour 
measures  about  two  inches  in  its  greatest  diameter,  and 
projects  forwards  over  the  right  canine  and  bicuspid  teeth. 
It  is  pale,  soft,  and  homogeneous,  and  the  surface  of  its 
section  is  like  that  of  brain.  At  the  upper  part  its  tissue 
is  broken,  and  was  mixed  with  blood  ;  in  its  recent  state  it 
was  more  brain-like.  The  patient,  William  Thomson,  was 
sixteen  years  old.  The  disease  had  been  observed  for  two 
years.  He  had  often  suffered  pain  in  the  situation  of  the 
first  molar  tooth,  which  had  been  in  a  decayed  state  for  a 
considerable  time  previous  to  his  discovering  any  swelling 


294 


MALIGNANT    TUMOUES    OF   THE    UPPER    JAW. 


of  the  cheek.  During  the  two  months  preceding  the 
operation  the  tumour  had  grown  rapidly.  Three  years  and 
a  half  after  its  removal  the  patient  was  in  good  health." — 
See  Liston's  paper,  Medico -CMrurgical  Transactions,  vol.  xx. 
In  this  case,  which  was  fortunately  submitted  to  operation 
at  a  very  early  period,  the  disease  was  still  confined  to  the 
antrum,  and  the  removal  of  the  jaw  therefore  included  the 
whole  of  it.  Unfortunately,  in  too  many  cases  the  disease 
is  much  more  advanced  before  it    is    brought    under    the 


Fig.  124. 


notice  of  the  surgeon,  when    therefore    the    possibility    of 
complete  extirpation  is  much  reduced. 

Eound-celled  sarcoma  of  the  jaw  closely  resembles  the 
same  disease  in  other  parts  of  the  body,  rapidity  of  growth, 
with  softness,  and  a  tendency  to  fungate  on  the  part  of  the 
tumour  itself,  being  the  main  characteristics.  The  direction 
which  the  disease  takes,  and  the  effects  therefore  w^hich  it  pro- 
duces, will  vary  in  different  examples.  Frequently  it  forms 
a  considerable  projection  on  the  cheek,  causing  epiphora  from 
closure  of  the  nasal  duct,  and  oedema  of  the  lower  eyelid ; 
and  in  the  later  stages  enlargement  of  the  facial  veins, 
without  the  least  invasion  of  the  hard  palate,  and  with  but 
slight  interference  with  the  nostril.  The  specimen  of 
medullary  sarcoma  represented  in  Tig.  124  (College  of  Sur- 


EOUND-CELLED    SAKCOMA    OF    THE    UPPER   JAT\".         295 

geons'  Museum),  illustrates  the  point,  a  large  tumour  being 
developed  externally.  The  patient  was  a  man,  aged  forty- 
four,  who  came  under  the  care  of  Mr.  Craven,  of  Hull,  in 
1863,  with  a  large  rounded  tumour  of  the  right  cheek,  of 
the  size  of  an  orange,  extending  from  the  external  process  of 
the  frontal  bone  and  zygoma  above,  to  the  angle  of  the 
mouth  below  (almost  completely  closing  the  right  eye),  and 
from  the  side  of  the  nose  to  the  ramus  of  the  lower  jaw. 
The  colour  of  the  integument  was  natural,  except  at  the 
upper  part  below  the  eye,  where  it  presented  a  rather  livid 
appearance,  and  several  veins,  not  of  large  size.  It  was 
very  firm  to  the  touch,  but  elastic,  especially  at  the  outer 
part.  Pressure  and  handling  caused  little  or  no  pain.  The 
interior  of  the  mouth  on  the  right  side,  from  the  alveolar 
process  (which  was  concealed  by  the  growth  or  embraced  in 
it)  to  the  inside  of  the  distended  cheek,  presented  a  large 
excavated  sore  of  a  greyish  sloughy  aspect  and  foetid  odour. 
This  part  of  the  tumour  was  softer  to  the  touch  than  that 
which  si  lowed  itself  externally.  It  did  not  encroach  on  the 
palate,  which  was  of  the  natural  width.  There  were  no 
enlarged  glands  beneath  the  jaw.  The  patient  seemed  a 
pretty  healthy  man.  The  tumour  had  been  growing  seven- 
teen weeks.  Mr.  Craven  excised  the  tumour,  and  the  patient 
made  a  good  recovery,  but  died  fifteen  months  afterwards 
from  a  recurrence  of  the  disease.  The  tumour  (Fig.  124) 
was  rounded  and  lobed,  especially  that  part  which  occupied 
the  pterygo-maxillary  fossa,  and  was  firm  on  section.  The 
cut  surface  was  smooth,  becoming  slightly  granular  after 
prolonged  exposure.  To  the  naked  eye  the  tumour  had  the 
appearance  of  a  malignant  growth.  Under  the  microscope, 
the  juice  scraped  oif  the  cut  surface  showed  no  fibrous 
element,  but  simply  a  mass  of  apparently  broken-up  cells 
and  granular  matter. 

On  the  other  hand,  the  disease  may  at  an  early  period 
involve  the  alveolus  and  palate,  or  the  nose,  and  it  is  these 
cases  which  are  sometimes  attributed  to  the  presence  of  de- 
cayed teeth,  or  are  mistaken  for  ordinary  nasal  polypi.  Of 
this,  a  preparation  which  is  shown  in  Fig.  125,  and  which 


296 


MALIGNANT    TUMOURS    OF    THE    UPPER    JAW. 


was  also  from  a  patient  of  Mr.  Craven  (to  whom  I  was 
mdebted  for  botli  valuable  preparations),  is  an  instance. 
Here  the  disease  showed  itself  first  in  the  gums,  where  it 
formed  a  fungating  mass,  and  soon  obstructed  the  nostril. 
This  last  symptom  was  due  to  a  fungus,  almost  papillary  in 
appearance,  which  springs  from  the  nasal  surface  of  the 
tumour.  Mr.  Craven  removed  the  tumour  in  March,  1866, 
but  within  a  year  the  disease  returned  and  proved  fatal. 

Fig.  125. 


The  disease  may  extend  across  the  median  line  and 
involve  portions  of  both  maxillse,  especially  the  palatine 
plates.  This  is  not  necessarily  a  bar  to  operative  inter- 
ference, provided  other  circumstances  are  favourable,  but 
when  the  disease  exhibits  the  appearance  shown  in  Fig.  126 
the  case  is  obviously  one  beyond  the  aid  of  surgery.  The 
patient,  aged  twenty-four,  was  sent  to  me  in  January,  1868, 
by  Mr.  Harding,  to  whom  he  had  applied  for  the  extraction 
of  some  teeth,  thinking  to  obtain  relief  thereby.  Four  and 
a  half  years  before  he  had  got  a  blow  on  the  face  from  a 
cocoa-nut,  which  broke  the  left  canine  tooth,  and,  a.  year 
before  I  saw  him,  the  left  side  of  the  face  swelled   up,  but 


ROUND-CELLED    SARCOMA    OF    THE    UI'PElt    JAW.         297 

subsided  again.  In  August,  1867,  he  first  noticed  a  growth 
below  tlie  left  eye,  which  rapidly  increased,  but  even  before 
this  the  interior  of  the  mouth  was  tender,  and  felt  swollen 
and  soft  to  the  touch.  He  had  good  advice  in  the 
country,  and  subsequently  was  in  a  London  hospital,  but 
operative  interference  was  declined  by  the  surgeon  under 
whose  care  he  was.  When  I  saw  him,  some  months  later, 
there  was  a  large  soft  tumour  of  the  left  upper  jaw,  and    a 

Fig.  126. 


smaller  one  on  the  right  side,  which  had  appeared  about 
four  weeks  before.  The  nose  was  considerably  projected  by 
these,  the  left  nostril  being  completely  blocked  and  the  right 
slightly  so.  The  alveolus  was  very  prominent,  so  that  the 
incisor  teeth  sloped  backwards,  and  there  were  soft  masses 
of  disease  on  each  side  of  the  palate.  Within  a  week  or 
ten  days  of  my  seeing  the  patient  the  lymphatic  glands 
in  the  neck  had  become  enlarged,  particularly  on  the  right 
side,  where  a  considerable  tumour  existed.  This  melan- 
choly case  was  obviously  totally  unfitted  for  operation  at 
the  time  I  saw  it,  whatever  might  have  been  its  prospects 
at  an  earlier  date.     I  could  therefore  hold  out  no  hope  of 


298 


MALIGNANT    TUMOUKS    OF   THE    TIPPER  JAW. 


alleviation  to  the  unfortunate  patient,  who  returned  to    the 
country. 

Eound-celled  sarcoma  occasionally  involves  both  upper 
and  lower  jaws,  beginning,  I  believe,  mostly  in  the  upper 
and  extending  to  the  lower.  Fig.  127  shows  a  good  instance 
of  this  in  a  man  who  was  under  my  care  in  1877,  with  an 
enormous  swelling  of  the  left  side  of  the  face.  I  ventured, 
under  chloroform,  to  introduce  my  finger  into  the  mouth  to 

Fig.  127. 


explore  the  extent  of  the  growth,  but  I  found  it  so  exten- 
sively attached  to  both  upper  and  lower  jaws  that  removal 
was  clearly  impossible.  The  examination  gave  rise  to 
sharp  haemorrhage,  due  to  the  great  vascularity  of  the  growth, 
and  this  was  checked  with  some  difhculty  with  the  per- 
sulphate of  iron. 

I  met  with  the  same  implication  of  the  lower  jaw,  though 
to  a  lesser  extent,  in  a  lady,  from  whom  I  removed  the  upper 
jaw  in  consultation  with  Dr.  Caesar.  In  this  case  the  coronoid 
process  was  involved  and  was  removed  with   bone-forceps, 


CAECINOMA    OF    THE    UlTER    JAW.  299 

but  recurrence  of  the  disease  took  place  and  the  patient  did 
not  survive  the  operation  four  months. 

2.  Carcinoma. — The  variety  of  cancer  that  occurs  in  the 
upper  jaw  is  always  epithelioma,  which  may  occur  in  two 
forms,  the  squamous  and  the  columnar.  The  former,  which 
probably  always  begins  in  the  gum  or  palate,  has  already 
been  described  in  connection  with  the  antrum,  6pithdioma 
ierdhrant  (see  p.  167).  Squamous  epithelioma  of  the  upper 
jaw  may  be  present  without  the  characteristic  invasion  of 
the  antrum.  The  rapidity  of  the  growth  in  such  cases  is 
well  illustrated  by  a  patient  I  attended  with  Mr.  Sams,  of 
Blackheath,  in  the  latter  part  of  1871.  A  lady,  aged  fifty- 
two,  had  noticed  a  small  growth  in  the  gum  of  the  left 
upper  jaw,  which  gradually  overlapped  the  hard  palate. 
This  was  removed  by  another  surgeon  in  May,  1 87  i,  but  the 
growth  reappeared  almost  immediately.  In  November  I 
found  a  fungus-looking  mass  involving  the  greater  part  of 
the  left  half  of  the  hard  palate,  the  bone  of  which  was 
absorbed,  and  bulging  up  beneath  the  cheek.  I  removed  the 
left  half  of  the  hard  palate,  with  the  whole  of  the  growth,  on 
November  24th.  In  ten  days  the  growth  reappeared  on  the 
apparently  healthy  section  of  the  hard  palate  and  also  in 
the  cheek.  A  fortnight  after  the  first  operation  I  therefore 
again  operated  very  freely,  applying,  as  on  the  former 
occasion,  a  strong  solution  of  the  chloride  of  zinc  to  the 
entire  wound.  Again,  within  ten  days,  the  disease  re- 
appeared and  rapidly  filled  up  the  cavity  left  by  the  opera- 
tion, blocking  the  nostril  and  mouth,  and  eventually  suffo- 
cating tlie  patient  in  her  sleep,  on  December  29th. 

Even  when  the  disease  is  far  advanced,  however,  so  that 
the  tissues  of  the  face  and  mouth  are  much  involved,  it 
is  sometimes  possible  for  the  surgeon  to  give  relief,  if 
not  permanent  cure,  by  completely  excising  the  morbid 
structures. 

A  case  illustrating  the  advantage  of  operating  in  cases  of 
epithelioma  where  a  cure  cannot  be  hoped  for,  was  under  my 
care  during  1 8  8  2-3 .  A  lady,  aged  fifty-two,  was  sent  to  me 
in  March,  1882,  by  Sir  Spencer  Wells,  with  the  following 


300  MALIGNANT   TUMOUES    OF   THE    UPPEK    JAW. 

history  :  A  niontli  before  Christinas,  1 8  8 1 ,  she  had  noticed 
a  swelling  of  the  left  cheek,  and  when  I  saw  her  had  a 
uniformly  elastic  swelling  involving  the  left  upper  jaw,  and 
spreading  up  the  margin  of  the  left  orbit.  The  skin  was 
tense  and  reddened,  but  not  involved  apparently^  and  the 
palate  was  healthy.  I  recommended  removal,  with  the 
view  of  prolonging  life,  and  in  this  view  Mr.  Erichsen 
coincided,  but  two  eminent  surgeons  had  given  a  contrary 
opinion. 

On  March  24th  I  turned  back  a  flap  of  the  cheek,  and  found 
the  tumour  well  covered  with  fascia  and  the  skin  healthy. 
I  opened  the  temporal  fascia,  so  as  to  isolate  the  growth 
behind,  and  divided  the  zygoma  afterwards,  clearing  the 
malar  bone,  and  sawing  the  external  angular  process  of  the 
frontal  bone.  The  palate  was  then  sawn  through,  and  the 
jaw  readily  removed.  The  remains  of  the  hard  palate  were 
removed  with  bone-forceps  quite  up  to  the  pterygoid  process, 
which  was  healthy,  and  the  parts  were  freely  cauterized  to 
make  doubly  sure.  The  patient  made  a  good  recovery,  and 
left  town  much  relieved  on  April  19th. 

In  September  I  saw  her  again,  when  there  was  an  epi- 
theliomatous  fungus  at  the  outer  angle  of  the  wound, 
measuring  i^  inches  across.  No  glands  were  enlarged,  and 
the  patient^s  health  continued  good.  On  September  28th,  I 
removed  the  growth  and  surrounding  skin  freely  with 
Paquelin's  cautery,  and  applied  chloride  of  zinc  paste.  The 
mouth  and  cavity  left  by  removal  of  the  upper  jaw  were 
quite  healthy,  but  the  mouth  could  not  be  opened  freely 
because  the  surface  of  the  lower  jaw  had  become  involved 
by  the  disease  in  the  cheek.  On  October  i  oth  a  recurrence 
of  disease  at  the  bottom  of  the  otherwise  healthy  wound  was 
noticed,  and  the  caustic  paste  was  re-applied. 

In  November  the  patient  returned  with  one  small  spot  of 
epithelioma  at  the  bottom  of  the  wound,  involving  the 
mucous  membrane  of  the  mouth.  This  was  thoroughly 
destroyed  with  caustic  paste,  and  the  parts  were  quite  sound 
when  the  patient  went  home.  In  February,  1883,  there 
was  a  fresh  recurrence  in  the  check,  but  the  patient  was  too 


COLUMNAR    EPITHELIOMA    OF    THE    UrPER    JAW. 


301 


weak  to  bear  treatment,  and  she  died  in  April,  having  sur- 
vived the  first  operation  more  than  a  year  in  comparative 
comfort,  and  with  no  formidable  external  tumour. 

Columnar  Epithelioma. — This  variety  of  carcinoma  always 
begins  in  the  antrum,  which  it  often  fills,  and  then 
secondarily  involves  the  palate  ;  or  it  may  attack  the 
outer  wall  only  of  the  antrum,  and  then  protrude  on  the 
face.  Occurring  usually  in  patients  over  forty  years  of  age, 
the  disease  begins  very  insidiously,  the  patient  complaining, 
perhaps,  of  neuralgia  or  of  uneasiness  in  the  face,  but  of  little 
more.  When  the  antrum  has  become  distended,  the  epithe- 
lioma   is    apt    to    involve    the   palate    by    absorption    and 

Fig.  128. 


eventual  fungation,  and  then  protrude  into  the  nostril  and 
orbits. 

A  case,  which  I  believe  to  be  of  this  nature,  was  brought 
to  me  by  Dr.  Whitmarsh,  of  Hounslow.  The  patient  was 
a  gentleman  who,  two  years  before,  had  jDcrceived  some 
growth  in  the  right  nostril,  which  gave  no  pain,  but  kept  up 
a  constant  discharge,  especially  at  night.  In  the  early  part 
of  the  year  this  had  been  removed  in  part  by  a  surgeon,  and 
since  then  the  discharge  had  much  increased.  There  was  a 
fungous  growth  in  the  right  nostril,  and  the  whole  right 
maxilla  was  swollen  and  discharged  thin  pus  at  one  or  two 
points  near  the  eye.  There  was  a  fungus-looking  growth 
in  the  molar  region,  and  a  probe  passed  by  its  side  into  the 
antrum. 

I  removed  the  disease  on  September  23rd,  clearing  away 
the    whole    of    the   growth,  which   was    very    friable,    and 


302  MALIGNANT    TUMOURS    OF   THE    UPPER    JAW. 

leaving  the  posterior  wall  of  the  antrum  and  the  infra-orbital 
plate  untouched.  In  the  course  of  the  operation  I  found  a 
distinct  polypoid  growth  filling  the  posterior  nares,  which  I 
removed.  The  patient  rallied  well  from  the  operation,  but 
unfortunately  got  congestion  of  the  lungs  and  died  on  the 
fifth  day. 

The  preparation  is  in  the  College  of  Surgeons'  Museum, 
and  the  appearance  of  a  part  of  the  disease  is  shown  in 
Fig.  128.  It  will  be  seen  that  the  interior  of  the  antrum 
is  covered  with  a  remarkable  papillary  or  villous  growth, 
resembling  some  forms  of  cauliflower  excrescence. 

In  1888  I  saw  with  Dr.  Brace  a  gentleman  aged  sixty, 
who  had  been  treated  for  a  persistent  discharge  from  the 
nose  and  a  gum-boil.  I  removed  the  upper  jaw,  and  the 
preparation,  in  the  College  of  Surgeons'  Museum,  shows  the 
epitheliomatous  disease  to  have  been  entirely  confined  to  the 
cavity  of  the  antrum,  though  protruding  into  the  middle 
meatus.  Nevertheless,  the  growth  rapidly  recurred  in  the 
parts  behind  the  jaw  and  eventually  destroyed  the  jDatient. 


CHAPTEK  XVIII. 

DIAGNOSIS  AND  TREATMENT  OF  TUMOUKS  OF  THE  UPPER  JAW. 

Diagnosis. — The  diagnosis  of  tumours  of  the  upper  jaw  is 
by  no  means  simple.  Even  the  distinction  between  fluid 
tumours  due  to  cystic  enlargement  of  the  jaw  and  solid 
growths,  is,  as  has  already  been  pointed  out,  not  always 
easy ;  and  it  is  still  more  difficult,  and  in  some  cases  im- 
possible, to  decide  as  to  the  malignancy  or  otherwise  of  a 
tumour  previous  to  its  extirpation. 

The  fibrous,  cartilaginous,  and  osseous  tumours  are  all  of 
slow  growth,  painlesSj  and  more  or  less  hard  to  the  touch. 
They  do  not  affect  the  general  health,  nor  do  they  show  any 
tendency  to  involve  the  surrounding  tissues  or  the  skin, 
except  by  mechanical  interference.  The  fibro-sarcomatous 
and  myeloid  tumours  are  more  rapid  in  their  growth,  and 
softer  than  those  already  mentioned  ;  both  are  more  vascular 
in  appearance  at  points  where  they  are  covered  only  by 
mucous  membrane.  They  occasionally  ulcerate,  but  do  not 
fungate,  and  may,  under  these  circumstances,  discharge 
blood  in  considerable  quantities.  The  meduUary-sarcoma- 
tous  and  epitheliomatous  tumours  are  the  most  rapid  in  their 
growth,  and  their  tendency  to  involve  surrounding  structures 
is  early  manifested.  The  softness  and  tendency  to  fungate 
are  the  chief  characteristics  of  medullary  sarcoma  and 
epithelioma,  but  these  must  not  be  relied  on  too  implicitly. 
This  last  variety  is  ordinarily  more  painful  than  the  others, 
the  patient  frequently  complaining  of  neuralgic  or  gnawing 
pains  in  the  head  and  face. 

In  examining  a  case  of  tumour  of  the  upper  jaw,  a  careful 
inspection  should   be  made  of  the  face,  mouth,  and  nares. 


304  OPEEATIONS  ON  THE  UPPEK  JAW. 

The  consistency  of  the  projection  beneath  the  cheek  should 
be  tested  with  the  finger  both  outside  and  inside  the  cheek 
itself.  The  condition  of  the  hard  and  soft  palate  should  be 
particularly  investigated,  and  the  finger  should  be  carried 
behind  the  soft  palate,  if  there  is  any  suspicion  that  the 
tumour  extends  towards  the  posterior  nares.  The  removal 
of  a  tooth  may  assist  in  the  diagnosis,  either  by  evacuating 
fluid,  or  by  bringing  away  with  it  a  small  portion  of  growth, 
which  may  be  submitted  to  microscopic  examination.  The 
condition  of  the  nostril  will  require  especial  examination, 
particularly  in  those  cases  where. the  disease  shows  itself  at 
an  early  period  in  that  cavity,  and  doubt  arises  as  to  its 
nature.  The  careful  introduction  of  a  probe  whilst  a  good 
light  is  thrown  into  the  nostril,  will  enable  the  surgeon  to 
decide  whether  the  tumour  is  merely  a  polypus  springing 
from  the  turbinate  bones,  or  whether  it  is  a  portion  of  an 
antral  tumour  showing  itself  in  the  nostril,  or  possibly  some 
growth  springing  from  the  base  of  the  skull  and  simulating 
maxillary  disease. 

Prognosis. — But  little  can  be  hoped  from  medicine  in  the 
treatment  of  tumours  of  the  upper  jaw.  The  application  of 
iodine  has  been  said  by  Mr.  Stanley  to  have  effected  the 
removal  of  a  small  enchondroma,  and  no  harm  will  be  done 
by  resorting  to  such  measures  and  to  the  internal  adminis- 
tration of  absorbent  medicines  for  a  short  time,  whilst  the 
progress  of  the  disease  is  watched,  provided  no  chemical 
agent  be  applied  to  the  growth  itself,  by  which  it  might  be 
irritated  or  caused  to  inflame.  Eemoval  by  surgical  opera- 
tion is,  however,  the  only  effectual  means  of  treatment,  and 
the  sooner  an  operation  is  undertaken  the  better  in  all  cases, 
since  even  a  benign  tumour  may,  by  its  size  or  by  its  attach- 
ments, put  a  patient's  life  in  danger  if  allowed  to  grow 
unchecked  for  a  series  of  years.  In  malignant  disease  the 
only  hope  for  the  patient  is  early  and  complete  removal, 
whilst  the  disease  is  confined  to  the  bone  and  before  the 
surrounding  structures  have  become  affected. 

Operations  on  the  Upper  Jaio. — From  early  times  portions 
of  the  upper  jaw,  and  particularly  the  alveolus,  were  occa- 


OPERATIONS  ON  THE  UPPER  JAW.  305 

isionally  removed  on  account  of  some  disease,  and  with  more 
or  less  permanent  success.  Mr.  Butcher,  who  has  labo- 
riously investigated  the  subject,  puts  the  earliest  case  in  1693, 
the  operator  being  Akoluthus,  a  physician  at  Breslau.  De- 
sault,  Garengeot,  Jourdain,  and  others  in  the  last  century 
removed  growths  from  the  jaw,  gouging  them  out  with 
chisels  with  partial  and  temporary  success  ;  and  Dupuytren 
especially  advocated  this  mode  of  treatment  in  his  Legons 
Orcdes,  and  frequently  practised  it,  removing  in  this  manner 
the  greater  part  of  the  upper  jaw  in  1824.  Charles  White, 
of  Manchester,  appears  also  to  have  successfully  operated  on 
a  patient,  from  whom  he  removed,  piecemeal,  nearly  the  whole 
of  the  upper  maxilla  during  the  last  century. 

The  late  Mr.  John  Lizars,  of  Edinburgh,  appears  to  have 
been  the  first  to  propose  removal  of  the  entire  superior 
maxilla    as    a  whole    in    1826,  when,  in    his  "  System  of 
Anatomical  Plates,"  he  showed  how,  anatomically,  it  would 
be  possible  to  remove  the  bone  without  injury  to  important 
and  vital  parts,  and  recommended  the  previous  deligation 
of  the  common  carotid  artery,  with  a  view  of  preventing 
haemorrhage.     Mr.  Lizars  did  not  have  an  opportunity  of 
carrying  his  proposition  into  effect  until  December,  1827, 
when,  notwithstanding  the  ligature  applied  to  the  carotid, 
the  haemorrhage  was  so  fearful  as  to  necessitate  a  discon- 
tinuance of  the  operation  (Lancet,  1829-30).      M.  Gensoul^ 
of  Lyons,  had,  however,  forestalled  Mr.  Lizars   quite   inde- 
pendently and  without  being   aware   of  his  proposition,  for 
in  May,  1827,  he  removed  the  entire  superior  maxillary 
bone,  with  a  part  of  the  palate,  from  a  boy  of  seventeen,  on 
account  of  a  large  fibro-cartilaginous  tumour.     The  incision 
employed  by  Gen  soul  was  a  vertical  one  from  the  corner 
of    the    eye    to    the    lip,  joined    midway  at    right    angles 
by  a  transverse  incision,  which  was  again  met  by  a  small 
vertical    incision    ascending   to   the   malar   bone.      By  the 
employment  of    the  mallet  and  chisel  the   jaw,  with  the 
tumour,  was  dislodged  and  removed  by  the   division  of  the 
palate.     Although  the  carotid  was  not  tied  the  hsemorrhage 
was    not  very  great,  and    the    patient   recovered. — (Lettre 

U 


306  OPERATIONS  ON  THE  UPPER  JAW. 

Chirurgiccde  sur  gitelques  Maladies  Graves  d%  Sinus  Maxillaire, 
par  A.  Gensoul). 

Mr.  Syme  operated  successfully  in  May,  1829  (Edinlurgh 
Medical  and  Surgical  Journal,  1829),  and  Mr.  Lizars  also 
operated  again  in  1829,  for  a  medullary  tumour,  which  was 
completely  removed  with  the  exception  of  a  small  portion 
attached  to  the  pterygoid  processes.  The  patient  had  become 
quite  convalescent,  when  she  died  suddenly  on  the  nine- 
teenth day  {London  Medical  Gazette,  vol.  v,  p.  92).  His 
third  and  successful  operation  was  in  1830  {Lancet,  1829- 
30),  and  from  that  time  removal  of  the  upper  jaw  became 
an  established  operation  in  surgery.  Mr.  Lizars  used  an 
incision  across  the  cheek  from  the  angle  of  the  mouth  to  the 
malar  bone,  or  when  the  tumour  was  very  large,  employed 
in  addition  an  incision  through  the  lip  into  the  nostril,  with 
a  vertical  cut  at  the  malar  bone.  With  the  saw  and  bone- 
forceps  the  maxilla  was  separated  from  its  attachments  and 
removed. 

Lizars'  example  was  followed  by  most  of  the  leading 
surgeons  of  the  day,  but  Mr.  Liston  requires  especial  notice, 
since  he  performed  some  of  the  earliest  and  most  important 
operations  of  the  kind,  and  in  his  essay,  which  has  been 
frequently  referred  to  {Medico-Cfhirurgical  Transactions, 
vol.  xx),  brought  the  subject  and  its  relations  to  various 
forms  of  disease  prominently  under  the  notice  of  the  pro- 
fession. Mr.  Liston  seems  to  have  been  strongly  impressed 
with  the  notion  that  malignant  disease  of  the  jaw  should  not 
be  interfered  with,  but  this  idea  does  not  prevail  among 
operating  surgeons  of  the  present  day,  for  it  is  felt  that  it  is 
better  to  act  upon  the  principle  which  guides  operations 
upon  cancerous  growths  in  other  parts  of  the  body — to 
remove  the  growths,  if  feasible,  in  the  hope  of  giving  at 
least  relief  if  not  a  permanent  cure. 

Syme,  Mott,  Velpeau,  Dieffenbach,  O'Shaughnessy,  Hey- 
felder,  Fergusson,  and  Butcher  may  be  mentioned  as  having 
performed  the  operation  of  excision  of  the  superior  maxilla 
repeatedly  and  successfully.  Noticing  the  considerable 
deformity  resulting  due  to  incision  from  the  angle  of  the 


REMOVAL  OF  THE  UPPER  JAW. 


307 


mouth,  which  necessarily  divides  the,  facial  nerve,  and  still 
more  when  a  flap  of  skin  has  been  reflected  from  the  face 
by  a  double  incision,  Sir  William  Fergusson  devised  the 
plan  of  carrying  the  incision  solely  through  the  median 
line  of  the  lip  into  the  nostril.  By  dissecting  up  the  tissues 
of  the  nose  and  taking  advantage  of  the  stretching  of  the 
skin  of  the  nostril,  room  may  thus  be  obtained  for  the 
removal  of  any  tumour  not  of  large  size ;  but  supposing  this 

Fig. 129. 


to  be  found  impracticable,  it  is  still  open  to  the  operator  to 
prolong  the  incision  round  the  ala  and  up  the  side  of  the 
nose,  and  in  the  case  of  large  tumours,  to  carry  it  in  a  curve 
below  the  orbit  to  the  malar  bone,  as  seen  in  Figs.  129  and 
130.  The  great  advantages  of  these  methods  are  that  the 
facial  nerve  and  facial  artery  are  divided  at  points  where 
their  size  is  of  no  consequence,  and  consequently  the  loss  of 
blood  and  the  subsequent  deformity  are  much  diminished ; 
and  also  that  the  scars  fall  in  such  positions  as  to  be  hardly 
noticeable. 

This  method,  adopted  by  Fergusson,  was  really  a  modifi- 
cation of  the  skin  incision  recommended  by  Liston.     The 


308 


OPEKATIONS  ON  THE  UPPEK  JAW. 


incision  througli  the  lip  and  round  the  ala  of  the  nose  was 
used  by  Liston  (Fig.  129),  but  he,  in  addition,  often  made 
another  incision  from  the  angle  of  the  mouth  towards  the 
outer  angle  of  the  orbit.  Fergusson  found  that  this  second 
incision  was  rarely,  if  ever,  necessary. 

The  method  of  proceeding  which  I  recommend  when  it  is 
necessary  to  remove  the  entire  upper  jaw  is  as  follows  : 

Fig.  130. 


(Fig.  130).  The  skin  having  been  reflected  in  the 
manner  described  above,  the  incisor  teeth  of  the  side  to  be 
removed  are  extracted  and  a  narrow  saw  with  a  movable 
back  passed  into  the  nostril.  With  this  the  alveolus  and 
hard  palate  are  divided,  and  a  small  saw  (Fig.  131)  is  then 
applied  to  the  malar  bone  in  a  line  with  the  spheno- 
maxillary fissure,  and  to  the  nasal  process  of  the  superior 
maxilla,  so  as  to  notch  both  these  points  of  bone,  the  division 
being  completed  with  the  bone-forceps.  With  the  '  lion- 
forceps,'  devised  by  Sir  William  Fergusson  for  the  purpose 
(Fig.  1 3  2),  the  jaw  can  now  be  grasped  and  broken  away 
from  the  pterygoid  process  and  palate  bone,  any  detaining 


REMOVAL  OF  THE  UPPER  JAW. 


309 


point  being  severed  with  the  bone-forceps.  Lastly,  when 
the  bone  is  quite  loose,  the  infra-orbital  nerve  is  to  be 
severed,  and  the  soft  palate  divided  at  its  attachment  to  the 
bone,  so  as  to  leave  as  much  of  it  as  possible  uninjured  ;  and 
any  remaining  portions  of  disease  are  then  to  be  removed 


Fig.  131. 


Fig.  132. 


with  the  bone-forceps  and  gouge.  Haemorrhage  is  to  be 
arrested  by  ligatures  and  the  application  of  the  actual 
cautery  to  the  deep  tissues,  and,  finally,  the  lip  and  incision 
are  to  be  brought  together  and  carefully  adjusted  with  hare- 
lip pins  and  interrupted  sutures  of  fine  wire  or  silk.  Figs. 
133  and  134  show  the  two  stages  of  the  operation. 

When  the  disease  is  of  less  amount,  and  the  orbital  plate 
is  not  involved,  this  should  be  preserved  by  carrying  a  saw 
horizontally  below  it ;  and  if  the  palate  is  not  involved,  this 
may  be  advantageously  kept  intact  by  making  a  similar  cut 


310 


OPERATIONS  ON  THE  UPPER  JAW. 


immediately  above  it.  Under  these  circumstances  the  inci- 
sions through  the  skin  need  only  be  very  limited,  and  the 
bone-forceps  and  gouge  will  be  requisite  to  clear  out  all  the 
disease  from  the  antrum. 

Sir  William  Fergusson  has,  in  his  "  Lectures  on  Anatomy 

and  Surgery,"  strongly  urged  the  pursuance  of  a  less  heroic 

plan  than  that  which  has  hitherto  been  followed,  in  going 

completely  beyond   and   not  interfering  with  the  diseased 

Fig.  133.  Fig.  134. 


■"^, 


tissues.  According  to  that  eminent  surgeon,  it  is  better  to 
cut  into  the  disease  and  to  clear  it  out  by  working  from  the 
centre  to  the  circumference,  so  as  not  to  remove  healthy 
structures  unnecessarily,  and  this  may  be  accomplished  by 
means  of  curved  and  angular  bone-forceps  of  various  sizes, 
and  by  the  use  of  the  gouge.  Mr.  Syme  {British  Medical 
Journal,  Aug.  1 2  th,  1865)  denounced  this  method  as  a  return 
to  "  the  old  system  with  its  chisels  and  gouges ; "  but  the 
practice,  as  regards  non-cancerous  tumours  at  least,  has 
recently  received  the  strong  support  of  Sir  James  Paget,  who 
in  a  paper  in  the  Medico- CMntrgical  Transactions,  vol.  liv, 


.  REMOVAL  OF  THE  UPPER  JA^V.  311 

has  urged  the  propriety  of  enucleating  simple  tumours 
growing  in  the  interior  of  hones,  and  among  other  cases 
gives  one  of  a  lad  of  nineteen,  from  whose  antrum  he  suc- 
cessfully removed  a  large  mass  without  injury  to  the  palate 
or  orbit.  A  similar  instance,  under  my  own  care,  is  given 
at  p.  264.  The  case  is,  however,  different  when  the  disease 
is  of  a  malignant  character,  and,  after  some  considerable 
experience,  I  am  decidedly  of  opinion  that  the  surgeon  must 
go  well  beyond  the  boundaries  of  the  tumour  if  he  hopes  to 
give  the  patient  permanent  relief.  The  practice  of  cutting 
into  a  malignant  growth  gives  rise  to  considerable  haemor- 
rhage, which  renders  it  very  difficult  to  be  certain  as  to  the 
removal  of  the  entire  disease.  It  is  better,  therefore,  I  think, 
to  cut  into  the  healthy  bone  beyond,  so  as  to  be  quite  certain 
of  removing  the  entire  growth,  though  it  is  by  no  means 
necessary  to  remove  large  portions  of  healthy  structure. 

In  cases  of  epithelioma,  where  even  the  whole  of  the 
diseased  structures  have  been  removed,  I  would  strongly 
advise  the  application  of  the  chloride  of  zinc  paste,  made 
with  hydrochloric  acid  and  opium,  after  the  formula  of  the 
Middlesex  Hospital.  Applied  on  the  end  of  a  strip  of  lint 
to  the  doubtful  part,  the  rest  of  the  lint  can  be  packed  in 
and  covered  over  with  a  pledget  of  cotton-wool,  so  as  to 
prevent  the  escape  of  the  chloride  of  zinc  into  the  mouth ; 
and  I  have  found  it  very  advantageous  to  plug  the  posterior 
nostril  on  the  affected  side  from  the  front  with  another 
strip  of  lint,  so  as  to  obviate  the  escape  of  fluid  into  the 
throat.  After  three  days  the  plugs  are  easily  withdrawn 
from  beneath  the  cheek,  and  free  syringing  will  keep  the 
parts  sweet  while  the  sloughs  caused  by  the  caustic  are 
separating.  For  washing  out  the  mouth  there  is  nothing 
better  than  the  syphon  nasal- douche  with  a  soft  nipple. 

In  cases  of  epithelioma  in  which  the  skin  is  involved,  the 
portion  so  diseased  must  be  sacrificed  if  a  cure  is  to  be 
hoped  for.  This  may  be  effected  with  the  knife  or  the 
actual  cautery,  and  I  may  refer  to  a  very  successful  example 
of  this  method  of  treatment  by  Mr.  Lawson,  recorded  in  the 
Clinical  Society's  Transactions,  vol.  vi. 


312  OPEEATIONS  ON  THE  UPPER  JAW. 

As  a  local  antiseptic  nothing  is  equal  to  powdered  iodo- 
form, freely  applied  to  the  raw  surfaces  both  of  bone  and  soft 
parts.  In  this  way  the  cavity  left  by  removal  of  the  upper 
jaw  may  be  kept  sweet  for  days  after  the  operation,  and  the 
patient  be  spared  the  risks  of  purulent  infection  or  septic 
bronchitis. 

It  has  been  mentioned  that,  in  the  earlier  operations  for 
removal  of  the  upper  jaw,  it  was  customary  to  apply  a  liga- 
ture to  the  common  or  external  carotid  artery.  Although 
this  practice  has  now  been  quite  abandoned,  it  has  in  a  few 
cases  been  necessary  to  secure  the  main  vessel  after  the 
operation,  on  account  of  secondary  haemorrhage.  Thus,  Mr. 
Field,  of  Brighton,  tied  the  common  carotid  two  days  after 
removal  of  the  upper  jaw,  in  1858,  and  the  patient  recovered. 
In  a  patient  of  Mr.  Holmes  Coote's,  at  St.  Bartholomew's, 
the  house-surgeon,  Mr.  Orton,  tied  the  vessel  on  the  nine- 
teenth day,  but  the  patient  sank  {Lancet,  October  13  th, 
1866).  In  his  work  on  Cancer,  Mr.  Oliver  Pemberton 
mentions  a  case  which  occurred  in  1848,  when  he  was 
house-surgeon  at  the  Birmingham  General  Hospital,  which 
also  proved  fatal. 

As  a  rule,  however,  patients  who  have  been  submitted  to 
removal  of  the  upper  jaw  recover  with  wonderful  rapidity. 
Of  course  the  primary  shock  of  such  an  operation  is  severe, 
but  when  this  is  once  got  over  the  convalescence  is  ordi- 
narily rapid. 

Eemoval  of  hoth  upper  jaws  has  occasionally  been  per- 
formed. A  case  in  which  Mr.  Lane  removed  the  greater 
part  of  both  jaws  has  been  referred  to  in  this  essay  (p.  290), 
and  the  operation  has  been  performed  by  Eogers,  of  New 
York  (1824),  Heyfelder  (1844,  and  twice  afterwards),  Dief- 
fenbach,  Maisonneuve,  and  others.  Heyfelder  made  two 
incisions  from  the  outer  angles  of  the  eyes  to  the  corners  of 
tlie  mouth,  and  reflected  this  quadrilateral  flap  to  the  fore- 
head, taking  the  nose  with  it.  He  then  passed  a  chain-saw 
through  the  spheno-maxillary  fissure  on  each  side,  and  thus 
separated  the  jaws  and  the  malar  bones.  The  junctions 
with  the  nasal   bones  and  vomer  were  then  divided  with 


.REMOVAL  OF  BOTH  UPPER  JAWS.  313 

bone-forceps,  and  the  soft  palate  separated  from  tlie  margin 
of  the  hard.  Lastly,  powerful  traction  upon  the  bones  was 
exerted,  and  the  bones  were  displaced.  Dieffenbach, 
Maisonneuve,  and  others,  employed  a  median  incision, 
beginning  at  the  root  of  the  nose  and  ending  in  the  median 
line  of  the  lip,  so  as  to  divide  the  skin  of  the  face  into  two 
lateral  flaps.  This  appears  to  be  an  unnecessary  complication, 
however,  since  division  of  the  lip  and  free  dissection  of  the 
nostrils  would  afford  sufficient  room  for  the  removal  of  the 
jaw  in  two  halves.  A  paper  on  Total  Double  Eesection  of 
the  Upper  Jaws,  by  H.  Braun,  of  Heidelberg,  will  be  found 
in  Langenbeck's  ArcJiiv,  xix,  1876. 

In  1872,  Mr.  Dobson,  of  Bristol,  removed  both  superior 
maxillae  of  a  woman,  aged  fifty-two,  by  dividing  the  lip  in 
the  middle  line  and  carrying  an  incision  up  each  side  of  the 
nose,  and  the  late  Mr.  Bellamy  informed  me  that  he  had 
removed  the  greater  part  of  both  upper  jaws  by  simply 
reflecting  the  lip  without  any  external  incision. 

Dr.  Charles  Brigham,  of  San  Francisco,  has  reported  in 
his  "  Surgical  Cases  with  Illustrations  "  (1876),  an  instance 
of  successful  removal  of  the  entire  upper  jaw  for  malignant 
disease,  after  performing  tracheotomy  and  plugging  the 
pharynx  with  sponge.  In  a  case  of  such  extensive  disease 
the  preliminary  tracheotomy  was,  no  doubt,  admirable,  but 
for  ordinary  cases  of  removal  of  tumours  of  the  upper  jaw 
the  proceeding  seems  to  me  uncalled  for,  as  I  have  never 
employed  it,  and  have  only  seen  it  employed  on  one  occasion. 
Professor  Trendelenburg's  proposal  to  perform  a  preliminary 
tracheotomy,  and  to  plug  the  trachea  by  a  special  expanding 
tampon  in  all  serious  operations  about  the  mouth,  was  made 
in  1 87 1,  and  will  be  found  described  at  length  in  the  Medical 
Times  and  Gazette  for  May,  1872.  I  have  employed  the 
tampon  once  in  operating  on  the  tongue,  and  once  (unneces- 
sarily as  it  turned  out)  in  operating  on  the  palate ;  but 
the  objection  to  it  is,  that  the  pressure  exerted  on  the 
trachea  is  apt  to  produce  great  embarrassment  of  breathing 
and  cough.  Plugging  the  pharynx  with  a  sponge,  to  which 
a  string  is  attached,  is  a  far  preferable  plan,  and  I  strongly 


314 


OPERATIONS  ON  THE  UPPER  JAW. 


advise  that  the  preliminary  tracheotomy  should  be  done  a 
couple  of  days  beforehand,  so  that  the  patient's  windpipe 
may  have  become  accustomed  to  the  presence  of  the  tube. 
On  two  occasions  I  have  been  obliged  to  perform  laryngo- 
tomy  in  order  to  suck  blood  out  of  the  wind-pipe. 

I  have  twice  had  occasion  to  remove  the  eye-ball 
in  cases  in  which  the  disease  had  spread  from  the 
jaw  to  the  orbit.     In  one  desperate  case,  in  which  I  only 

Fig.  135. 


operated  at  the  earnest  request  of  the  patient,  I  removed 
the  eye-ball  and  the  eye-lids,  and  stitched  up  the  opening, 
the  patient  being  able  to  return  to  India,  and  surviving 
several  months.  In  a  remarkable  case  of  recurrent  sarcoma, 
on  which  I  operated  five  times  with  ultimate  success,  it 
became  necessary  to  remove  the  eye-ball  after  the  second 
operation,  as  it  had  suppurated.  Eig.  135  shows  the 
appearance  of  the  patient  at  the  present  time  (1894),  ten 
years  after  the  last  operation.  The  prominence  seen  in  the 
cavity  of  the  orbit  is  the  top  of  a  vulcanite  palate,  and 
ordinarily  the  deformity  is  concealed  by  a  black  patch. 


HEMORRHAGE    AND    SHOCK.  315 

The  fear  of  hcemorrhage  in  cases  of  removal  of  the  upper 
jaw  is  exaggerated,  I  think,  for  there  is  no  large  vessel 
implicated  until  the  last  stage  of  the  proceeding,  when  the 
bone  is  forcibly  displaced  ;  and  then,  if  the  operator  is  rapid 
in  his  movements  and  his  assistants  are  prompt,  pressure  can 
be  made  with  a  sponge,  thrust  into  the  cavity,  quite  sufficient 
to  prevent  blood  flowing  into  the  fauces,  until  the  operator 
is  ready  to  pick  up  the  bleediag  vessel.  I  always  provide 
myself  with  a  small  sponge,  which  I  thrust  into  the  posterior 
nostril  of  the  affected  side  the  moment  the  larger  sponge 
held  by  an  assistant  is  removed.  This  prevents  any  blood 
flowing  into  the  pharynx,  and  allows  of  deliberate  examination 
and  the  arrest  of  bleeding  by  the  ligature  or  the  cautery. 

As  regards  the  position  of  the  patient  I  always  have  him 
recumbent,  with  the  head  fairly  raised  on  pillows,  and  in- 
variably employ  chloroform  as  the  ansesthetic,  both  because 
it  is  impossible  to  keep  a  patient  under  the  influence  of 
ether  when  air  must  necessarily  be  admitted  very  freely  by 
the  manipulations  of  the  surgeon,  and  because  of  the  danger 
of  ignition  of  the  vapour  of  ether  in  the  patient's  mouth  by 
the  application  of  the  actual  cauteiy. 

In  operating  upon  cases  in  which  unusual  haemorrhage 
was  anticipated,  I  have  adopted  the  plan  of  bringing  the 
patient's  head  well  over  the  end  of  the  table,  and  to  a  lower 
level  than  the  larynx,  so  that  the  blood  may  pour  out  of  the 
nostrils.  The  practice  is  an  inconvenient  one,  both  for  the 
operator  and  the  assistants,  but  it  may  be  advantageously 
adopted  if  necessary  in  the  later  stages  of  an  operation. 

Since  it  is  unadvisable  that  a  patient  about  to  have  a  jaw 
removed  should  take  food  for  four  hours  beforehand,  lest 
sickness  should  be  induced  by  chloroform  or  swallowing 
blood,  I  am  inclined  to  recommend  a  practice,  which  I 
have  lately  followed,  on  the  suggestion  of  Dr.  Prince,  of 
Jacksonville,  Illinois  (St.  Louis  Medical  and  Surgical  Journcd, 
February,  1883) — viz.,  to  inject  into  the  colon,  shortly 
before  a  severe  operation,  a  quantity  of  hot  brandy  and 
water,  suited  to  the  age  and  requirements  of  the  patient. 


CHAPTEK  XIX. 


N0N-MALIGNANT    TUMOUKS    OF   THE    LOWER   JAW. 


The  fallacies  that  surround  statistical  tables  constructed 
from  cases  occurring  several  years  ago  have  already  been 
mentioned  in  connection  with  tumours  of  the  upper  jaw, 
(see  p.  257).  It  is  convenient,  however,  for  the  sake  of 
comparison,  to  copy  0.  Weber's  table  of  tumours  of  the 
lower  jaw. 


Osseous  tumours  .           .           .          . 

25 

Vascular  tumours 

2 

Fibrous  tumours  .           .           .           . 

23 

Sarcomatous  tumours     . 

.      132 

Enchondromatous  tumours 

14 

Osteo-chondromata 

18 

Cystic  tumours 

25 

Carcinoma 

162 

Melanosis 

2 

403 

The  general  opinion  is  that  sarcomata  are  more  common 
than  carcinomata,  as  in  the  case  of  the  upper  jaw. 

Fibroma. — This  is  the  commonest  form  of  tumour  of  the 
lower  jaw,  and,  as  pointed  out  by  Paget,  it  may  be  central 
or  endosteal,  and  peripheral  or  periosteal. 

Central  or  Endosteal  Fibroma. — It  is  very  difficult  to 
account  for  the  origin  of  these  growths.  According  to 
Broca  the  great  majority,  if  not  all  of  them,  originate  in  a 
tooth  follicle  and  are  to  be  classified  as  odontomata. 
Virchow,  on  the  other    hand,  looks  upon  them  as  ordinary 


FIBKOMA  OF  THE  LOWEK  JAW. 


317 


fibromata.       It  is  possible  that  they  originate    in    an    in- 
flammatory   deposit     due    to    the    irritation     of     decayed 

teeth. 

If   we  exclude  those  originating  in  tooth  follicles  it  is 
difficult  to  say  in  what  structure  they  arise.     It  is  most 

Fig.  136. 


likely  that  they  commence  in  the  alveolo-dental  periosteum. 
The  formation  of  fibrous  tumours  between  the  plates  of  the 
lower  jaw  has  been  already  referred  to  under  the  head  of 
Inflammation  (p.  100),  and  originates,  I  believe,  in  the 
majority  of  cases  in  some  inflammatory  deposit  due  to  the 
irritation  of  decayed  teeth. 

By  the  slow  growth  of  the  tumour  the  jaw  is  expanded,  the 
outer  plate  yielding  more  readily  than  the  inner,  as  is  well 
seen  in  a  preparation  in  University  College  Museum  (Fig.  1 36), 
which  also  shows  a  curious  transportation  of  the  wisdom 
tooth  close  up  to  the  condyle  of  the  jaw  by  the  growth  of 
the  tumour,  being  probably  connected  with  it  in  some  way. 
In  the  College  of  Surgeons'  Museum  is  a  good  specimen 


318         NON-MAUGNAJSTT   TUMOUKS   OF   THE   LOWER   JAW. 

of  endosteal  fibrous  tumour,  wliich  Sir  Spencer  Wells 
removed  with  the  jaw  from  the  symphysis  to  the  angle, 
in  a  woman,  aged  twenty-seven.  The  tumour  occupied 
the  left  side  of  the  lower  jaw,  and  had  existed  for  four 
years,  being  connected  with  decayed  teeth,  one  of  which  on 
being  extracted  shortly  before  the  operation  brought  a  small 

Fig.  137. 


portion    of    the    tumour    away    with    it    (see    Pathological 
Society's  Transactions,  vol.  xii.). 

It  may,  I  think,  be  doubted  whether  a  milder  treatment 
than  that  of  removal  of  the  whole  thickness  of  the  bone 
containing  tumours  of  this  description  might  not  sometimes 
be  adopted  with  advantage.  A  specimen  in  the  Museum 
of  King's  College,  which  is  represented  in  Fig.  137, 
admirably  illustrates  this  view.  It  is  a  fibrous  tumour  re- 
moved, when  I  happened  to  be  present,  by  Sir  William  Fer- 
gusson,  from  a  woman  who  had  undergone  two  previous 
operations.  Having  sawn  the  jaw  partly  through  on  each 
side  of  the  tumour,  the  operator  applied  the  bone-forceps 
to  complete  one  of  the  sections,  when  the  oater  plate  of  the 
jaw  with  the  greater  part  of  the  tumour  came  away,  leaving 
only  a  small  portion  of  it  adhering  to  the  inner  plate.     Owing 


FIBEOMA  OF  THE  LOWER  JAW.  319 

to  the  jaw  being  already  divided,  it  was  considered  better  to 
complete  the  operation  as  originally  intended,  and  the 
patient  made  a  good  recovery.  The  preparation  referred  to 
illustrates  also  the  connection  of  the  teeth  with  fibrous 
tumours,  a  diseased  molar  tooth  being  implanted  in  the 
upper  part  of  the  growth. 

The  advantage  of  not  breaking  the  line  of  the  lower  jaw 
has  been  already  insisted  upon  in  connection  with  epulis, 
and  the  same  advantage  would  be  gained  by  preserving, 
where  possible,  the  inner  plate  of  the  jaw  in  cases  of 
tumour. 

I  have  recently  had  a  patient  under  my  care  who  had  a 
fibrous  tumour  of  the  size  of  a  large  marble,  in  the  lower  jaw, 
in  the  position  of  the  right  molar  tooth.  This  was  imbedded 
between  the  plates  of  the  jaw,  and  had  considerably  ex- 
panded the  bone.  I  succeeded  in  removing  the  growth 
from  within  the  mouth  by  means  of  the  large  forceps 
shown  in  Fig.  io8,  and  the  patient  made  a  good  re- 
covery. Sir  J.  Paget,  in  the  paper  already  referred  to 
(p.  311),  gives  two  cases  in  which  he  successfully  removed 
tumours  from  within  the  lower  jaw,  one,  a  bony  tumour, 
and  the  other,  and  more  remarkable  one,  a  cartilaginous 
growth  which  was  removed  by  the  gouge,  and  did  not 
reappear. 

A  specimen  of  fibrous  tumour,  presented  to  the  College  of 
Surgeons'  Museum  by  Mr.  Bryant,  illustrates  the  same 
point.  The  section  shows  that  the  fibrous  tumour  is  free 
towards  the  alveolar  border  of  the  jaw,  but  enclosed  in  the 
bone  below.  It  is  separated  at  all  parts  from  the  osseous 
tissue  by  a  fibrous  layer  forming  a  kind  of  capsule,  and 
might  therefore  probably  have  been  enucleated  from  its 
cavity  without  any  great  difficulty. 

A  specimen,  now  in  the  Museum  of  the  College  of  Sur- 
geons, and  for  which  I  was  indebted  to  Mr.  Buxton  Shillito, 
shows  the  satisfactory  result  of  the  treatment  here  recom- 
mended. The  case  is  reported,  with  drawings,  in  the 
Pathological   Transactions,  vol.  xvi,    and  the    tumour    was 


320       NON-MALIGNANT  TUMOURS    OF    THE    LOWER    JAW. 

removed  by  Mr.  Shillito  from  near  the  angle  of  the  lower 
jaw  of  a  young  woman,  aged  twenty-six,  where  it  had  been 
growing  fifteen  months,  being  of  the  size  of  a  walnut.  It 
was  removed  by  reflecting  a  flap  of  skin  from  its  surface, 
cutting  through  the  thin  shell  of  bone,  and  enucleation. 
It  left  a  perfectly  smooth  cavity  into  which  the  fang  of  the 
second  molar  tooth  projected,  which  doubtless  was  the 
original  cause  of  the  mischief.  The  tumour  was  gritty  on 
section,  and  furnished  an  example  of  calcification,  to  which 

Fig.  i-;8. 


^i 


change  fibromata  of  the  lower  jaw  are  liable  no  less  than 
those  of  the  upper  jaw. 

Though  of  slow  growth  under  ordinary  circumstances,  a 
fibrous  tumour  of  the  jaw,  if  irritated  by  the  injudicious 
application  of  useless  remedies  with  the  view  of  producing 
absorption  of  the  growth,  may  assume  enormous  proportions, 
and  destroy  life  by  the  irritation  and  continuous  discharge 
it  gives  rise  to.  A  preparation  in  King's  College  Museum 
shows  a  fibrous  tumour  of  large  size,  involving  nearly  the 
whole  of  the  left  side  of  the  lower  jaw.  Its  interior  is 
hollowed  out  into  a  large  cavity  with  sloughing  walls,  and 
there  is  a  large  aperture  communicating  with  it  surrounded 
by  healthy  skin.     The  patient's  portrait,  taken  about  six 


FIBROMA    OF    THE    LOWER    JAW. 


:?2i 


weeks  "before  lier  death,  is  seen  in  Tig.  138.  The  case 
was  evidently  one  of  ordinary  fibrous  tumour  depending 
originally  upon  diseased  teeth,  which,  by  dint  of  incisions 
and  injections  of  iodine  into  the  growth,  followed  by  a  setoii 
introduced  through  the  skin,  was  brought  into  such  a  con- 
dition that,  upon  the  receipt  of  a  blow,  it  rapidly  brought 
the  patient  to  her  deathbed. 

A   remarkable  and    unique  feature    in  connection  with 
the  case  of  large  fibrous  tumour  above  referred  to,  is  seen 

Fig.  139. 


in  Fig.  139,  which  shows  the  front  of  the  base  of  the 
skull  of  the  patient.  The  long-continued  pressure  of  the 
tumour  of  the  lower  jaw  has  given  rise  to  a  remarkable  con- 
traction of  the  hard  palate  and  alveolus,  the  teeth  being 
crushed  together  so  as  to  overlap  one  another,  and  at  the 
same  time  an  expansion  of  the  malar  bone  and  zygoma  has 
ensued,  which  is  accurately  shown  in  the  drawing. 

A  large  tumour  of  the  same  kind,  weighing  eighteen 
ounces,  which  has  encroached  upon  the  condyle  and  coro- 
noid  process,  and  projected  into  the  mouth  as  well  as 
on  the  surface,  is  preserved  in  University  College  Museum 
and  was  removed  by  Mr.  Liston  in  1846  ;  and   a  similar 

X 


322         NON-MALIGNANT    TUMOURS    OF    THE    LOWER    JAW. 

growth,  successfully  removed  bj^  Prof.  William  Beaumont,  of 
Toronto,  from  a  boy  of  seven,  which  is  considerably  infiltrated 
with  calcareous  matter,  is  in  the  Museum  of  the  College 
of  Surgeons,  and  was  originally  considered  to  be  carti- 
laginous (Medico- Chirurgical  Transactions,  vol.  xxxiii).  It 
weighed  eight  ounces  avoirdupois,  with  a  long  diameter  of 
3  inches,  and  a  short  diameter  of  2  inches,  and  involved  the 
whole  of  the  left  side  of  the  bone. 

Fibrous  tumour  is  most  frequently  developed  in  the  side 
of  the  lower  jaw,  where  the  space  between  the  plates  is 
larger  than  elsewhere,  and  may  occupy  the  dental  canal, 
as  in  a  case  of  Mr.  Cock's,  in  which  the  dental  nerve 
passed  through  the  tumour,  necessitating  its  removal  in 
two  parts  (Guy's  Hospital  Museum).  Occasionally,  how- 
ever, fibrous  tumour  invades  the  symphysis,  and  here, 
owing  to  restricted  amount  of  expansion  of  which  the  bone 
is  capable,  absorption  of  the  anterior  surface  takes  place  at 
an  early  date,  and  the  tumour  projects,  involving  also  the 
adjacent  bone.  A  preparation  in  University  College  shows 
the  symphysis  affected  in  this  way,  which  was  removed, 
with  a  portion  of  healthy  bone  on  each  side,  by  Mr.  Liston. 
A  section  shows  the  structure  very  well,  and  at  the  lower 
part  a  small  cyst  has  been  developed.  In  connection 
with  this  subject  another  preparation  in  the  same 
museum  is  deserving  of  notice,  being  a  fibrous  tumour, 
of  the  size  of  an  orange,  connected  with  the  back  of  the 
symphysis,  and  apparently,  therefore,  of  the  periosteal 
variety. 

Peripheral  or  Periosteal  Fibroma. — This  growth  may  be 
very  difficult  to  distinguish  from  epulis.  It  does  not 
tend  to  recur,  however,  after  removal,  as  an  epulis  does, 
and  it  attains  a  much  greater  size.  Like  epulis  it  has 
spicula  of  bone  springing  from  the  jaw,  permeating  it  for  a 
short  distance,  and  beyond  them  radiating  lines  may  be  seen 
in  the  fibrous  tissue.  A  preparation  in  the  Museum  of 
the  College  of  Surgeons,  which  accompanied  this  essay,  and 
for  which  I  was  indebted  to  Mr.  Lee  of  the  Salisbury 
Infirmary,  illustrates    this  form  of  disease  very  well,   the 


EXCHONDKOMA   <JF    THE    LOWER    JAW.  />2o 

fibrous  growth  being  closely  connected  with  the  periosteum 
of  the  front  of  the  jaw.  The  disease  may,  however,  almost 
completely  surround  the  jaw,  as  in  the  preparation  in  St. 
Bartholomew's  Hospital,  drawn  by  Sir  James  Paget  in  his 
"  Surgical  Pathology." 

Enchondroma. — This  growth  is  by  no  means  a  common 
one,  and  is  found  in  two  forms,  the  central  or  endosteal,  and 
the  peripheral  or  periosteal,  thus  resembling  fibroma. 

The  disease  generally  occurs  early  in  life,  and  makes  slow 
but  steady  progress,  the  periosteal  variety  acquiring  a  very 
large  size. 

Central  Enchondroma. — A  specimen  in  Guy's  Hospital 
Museum  shows  very  well  the  relation  of  the  endosteal 
variety  to  the  bone,  the  growth  occupying  the  space 
between  the  plates  of  the  jaw,  and  the  teeth  being  im- 
bedded in  it.  The  specimen  was  removed  by  Mr.  Aston  Key 
from  a  woman,  aged  twenty-nine,  in  whom  it  had  been  grow- 
ing nine  years,  by  sawing  through  the  bone  on  each  side 
of  the  tumour. 

A  somewhat  similar  case  is  recorded  by  Sir  Astley  Cooper 
in  his  "  Essay  on  Exostosis."  The  patient  was  nineteen,  and 
had  had  a  growth  in  the  side  of  the  lower  jaw  for  three 
years.  Sir  Astley  exposed  the  tumour  and  gouged  it  away, 
exposing  the  dental  nerve,  and  the  patient  made  a  good 
recovery. 

Sir  James  Paget  has  recorded  {Mcdico-Chirurgical  Trans- 
actions, 1 871),  a  very  similar  case  of  cartilaginous  tumour 
in  the  lower  jaw  of  a  lady  forty -five  years  old.  It  had  been 
growing  during  two  or  three  years,  extended  along  the  space 
between  the  first  bicuspid  and  last  molar  teeth,  was  deep 
set  in  the  jaw,  expanding  both  the  walls,  and  rising  to 
almost  the  level  of  the  molar  teeth.  He  gouged  it  out, 
leaving  the  base  of  the  jaw  untouched,  and  not  cutting  any 
part  of  the  cheek  or  lip.  The  patient  had  no  return  of  the 
disease. 

Periosteal  Chondroma. — The  periosteal  form  of  chondroma 
springs  from  the  membrane  covering  any  portion  of  the 
bone,  but  most  frequently  affects  the  body.      It  grows  to 


324        NON-MALIGNANT    TUMOUES    OF    THE    LOWER    JAW. 

an  enormous  size,  and  may  cause  death  either  by  interfering 
with  respiration,  as  in  Sir  Astley  Cooper's  case ;  or  with 
deglutition,  as  in  the  case  from  which  the  preparation  in 
the  College  of  Surgeous'  Museum  was  taken. 

Sir  Astley's  patient  was  a  girl  of  thirteen,  in  whom  the 
tumour  had  made  its  appearance  near  the  chin  a  year  before 
she  came  under  that  surgeon^s  notice.  The  tumour  increased 
until  it  measured  five  inches  and  a  half  from  side  to  side, 
and  four  inches  from  the  incisor  teeth  to  its  anterior  project- 
ing part.  The  circumference  of  the  swelling  was  sixteen 
inches.  The  tongue  was  thrust  back  into  the  throat  and  to 
the  right  side,  where  it  rested  in  a  hollow  between  the  angle 
of  the  jaw  and  the  tumour.  The  epiglottis  was  bent  down 
upon  the  rima  glottidis  so  as  to  produce  great  difficulty  in 
swallowing  and  breathing.  The  mental  foramen  was  large 
enough  to  admit  the  little  finger,  and,  owing  to  the  elongation 
of  the  bone,  was  directed  backwards.  The  preparation  is 
preserved  in  the  Museum  of  St.  Thomas's  Hospital  and  a 
section,  which  has  been  macerated,  shows  very  well  the 
ossific  spicula  from  the  surface  of  the  bone  projecting  into 
the  mass. 

In  the  Museum  of  the  College  of  Surgeons  is  a  still 
more  remarkable  specimen  of  the  same  disease,  the  tumour 
measuring  six  inches  in  depth  and  about  two  feet  in  cir- 
cumference, and  involving  the  whole  of  the  lower  jaw  ex- 
cept the  right  ramus  and  angle.  The  patient,  when  thirty- 
two,  had  a  small  hard  tumour  on  the  right  side  of  the  lower 
jaw,  just  below  the  situation  of  the  first  molar  tooth,  which 
had  decayed.  This  gradually  increased,  and  ultimately 
proved  fatal  at  the  end  of  eight  years,  by  inducing  inability 
to  swallow. 

A  specimen  of  chondroma,  weighing  three  and  a  half 
pounds  (German),  removed  by  disarticulation  by  Chelius,  is 
preserved  in  the  Heidelberg  Museum,  and  is  figured  by  Otto 
Weber  (pp.  cit.). 

A  remarkable  case  of  chondroma  of  the  lower  jaw  has 
been  recorded  by  Mr.  Lawson  {Pathological  Society's  Trans- 
actions, xxxiv),  in  which  there  were  ten  operations  for  as 


OSTEOMA    OF    THE    LOWER    JAW. 


Vli 


many  recurrences  during  eighteen  years.  The  report  of  a 
committee  on  some  of  the  more  recent  recurrences  goes  to 
show,  however,  that  these  are  more  of  the  nature  of  spindle- 
celled  sarcoma. 

The  patient,  a  woman,  aged  forty-five,  came  under  Sir 
William  Fergusson's  care  in  1865.  He  removed  the  tumour 
and  subsequently  operated  five  times  for  recurrent  growths. 

Fig.  140. 


In  1877  she  came  under  the  care  of  Mr.  Lawson,  and  her 
condition  then  is  shown  in  Fig.  140.  The  tumour,  together 
with  a  portion  of  the  lower  jaw,  was  removed,  and  is  seen  in 
Fig.  141.  Since  1877  five  operations  have  been  performed 
for  recurrent  masses  of  cartilaginous  growth.  This  is  un- 
doubtedly a  case  of  chondro-sarcoma  with  a  very  low  degree 
of  malignancy. 

Osteoma. — This  growth  occurs  in  the  lower  jaw  in  two 
forms ;  the  cancellated  and  the  ivory  exostosis.    The  former 


326        NON-MALIGNANT    TUMOUES   OF    THE    LOWER    JAW. 

may  be  in  many  cases  the  result  of  ossification  of  enchon- 
droma,  as,  for  instance,  a  specimen  preserved  in  St.  Thomas's 
Museum,  which  is  of  a  spongy  texture,  and  which  is  stated 
by  Sir  Astley  Cooper  to  have  been  removed-  by  Mr>  Cline. 
Occasionally,  however,  a  conversion  of  the  whole  thickness 
of  bone  into  a  lobulated  mass  of  spongy  bone  is  met  with, 
of  which  an  excellent  example  is  preserved  in  St.  George's 
Hospital  Museum.  In  this  case  the  tumour,  which  was  of 
the  size  of  the  fist,  had  been  growing  for  five  years,  and  had 

Fig.  141. 


been  on  one  occasion  partially  removed.  Mr.  Tatum  success- 
fully removed  the  entire  portion  of  jaw  affected.  A  case  in 
which  a  circumscribed  bony  tumour,  measuring  from  two- 
thirds  to  three-fourths  of  an  inch  iii  diameter,  and  composed 
of  hard,  finely  cancellous  bone,  was  lodged  in  the  interior  of 
the  angle  of  the  jaw,  is  given  by  Sir  J.  Paget  in  the  Medico- 
Chirurgical  Transactions,  vol.  liv. 

Ivory  exostosis  appears  to  affect  by  preference  the  angle 
of  the  jaw.  Of  this  a  good  specimen  is  preserved  in 
St.  George's  Hospital ;  and  0.  "Weber  figures  a  section  of  a 
large  ivory  exostosis  in  the  same  region  removed  by  Chelius. 
The  best  example  of  the  kind,  however,  is  in  the  College  of 
Surgeons,  having  been  presented  by  Mr.  J.  F.  South.     The 


OSTEOMA    OF    THE   LOWER    JAW. 


827 


preparation  (post-mortem)  shows  part  of  the  right  side  of 
the  lower  jaw,  with  sections  of  a  large  bony  tumour  at  its 
angle.  The  angle  of  the  jaw  rests  in  a  deep  groove  on  the 
middle  of  the  upper  surface  of  the  tumour,  and  in  some 
situations  their  respective  substances  are  continuous.  The 
tumour  projects  both  below  and  on  each  side  of  the  jaw,  is 
of  irregular  shape,  measures  nearly  three  inches  in  its  chief 
diameter,  and  is  deeply  nodulated.  It  is  composed  through- 
out of  bone,  uniform  in  texture,  and  as  hard  and  heavy  as 
ivory  (Fig.  142). 

Fig.  142. 


In  the  Museum  of  St.  Bartholomew's  Hospital  is  the  lower 
jaw  of  a  young  person  with  two  symmetrical  eburnated 
exostoses  springing  from  the  inner  surface  of  the  alveolar 
portion  of  the  bone  on  either  side  of  the  symphysis,  corre- 
sponding in  position  to  the  bicuspid  and  first  molar  teeth. 
The  markings  and  slight  lobulations  of  the  bony  outgrowths 
are  more  or  less  symmetrical.  The  rami  of  the  jaw  are 
unusually  widely  separated. 

In  May,  1870, 1  removed  an  ivory  exostosis  from  a  young 
woman,  aged  thirty-two,  a  patient  of  Mr.  Ceely,  of  Aylesbury, 
whose  portrait  is  given  in  Tig.  143.  There  had  been  a 
painless  enlargement  of  the  left  side  of  the  lower  jaw  for 


328        NON-MALIGNANT    TUMOURS    OF    THE    LOWER    JAW. 

five  years,  and  there  was  also  a  smaller  enlargement  of  the 
right  side.  A  small  exostosis  also  existed  on  the  left  pubes. 
I  made  an  incision  behind  the  jaw  and  sawed  off  the  growth 
level  with  the  bone,  removing  a  dense  ivory  growth,  measuring 
two  inches  in  length  by  one  inch  in  width,  and  three-eighths 
of  an  inch  thick  in  the  centre  (University  College  Museum). 
The  exterior  of  the  growth  presented  a  finely  reticulated 
appearance,  and  at  the  upper  part  was  a  small  depression 
filled  with  cartilage  in  the  recent  state.    Two  years  after  the 

Fig.  143. 


operation  I  was  informed  by  Mr.  Ceely  that  there  had  been 
no  reappearance  of  the  growth,  and  that  the  other  exostosis 
remained  in  statu  quo,  and  four  years  later  I  saw  the  patient, 
who  continued  quite  well. 

When  the  exostosis  forms  a  distinct  and  circumscribed 
growth,  whether  it  be  of  the  cancellous  or  ivory  character,  it 
should  be  sawn  off  the  bone  at  the  level  of  the  healthy 
surface,  and  will  in  all  probability  not  recur.  When,  how- 
ever, the  whole  thickness  of  the  bone  is  involved,  as  in  Mr. 
Tatum's  or  Mr.  South's  case,  it  will  be  necessary  to  remove 
a  portion   of  the  bone.      Should    the   tumour  be  imbedded 


OSTEOMA    OF    THE   LOWER    JAW.  329 

between  the  plates  of  the  jaw,  it  should  be  enucleated  if 
possible  without  any  external  incision,  as  in  Sir  J.  Paget's 
case  given  above.  A  remarkable  case  of  exostosis  of  the 
ramus  of  the  jaw,  reaching  to  the  styloid  process,  has  been 
recorded  by  Mr.  Syme,  in  his  "  Contributions  to  the  Patho- 
logy and  Practice  of  Surgery,"  in  which  he  removed  the 
ramus  of  the  jaw,  with  the  growth,  by  an  external  incision, 
without  opening  the  cavity  of  the  mouth. 


CHAPTEE  XX. 

MALIGNANT    TUMOUES    OF    THE    LOWER    JAW. 

Sarcoma  and  Carcinoma. 

The  classification  adopted,  when  describing  malignant 
tumours  of  the  upper  jaw,  will  be  employed  in  dealing  with 
the  similar  tumours  of  the  lower  jaw. 

I.  Sarcoma. — As  in  the  case  of  the  upper  jaw,  so  in  the 
lower  jaw,  we  must  distinguish  between  the  central  and  the 
periosteal  sarcomata ;  the  latter  occurring  more  frequently 
than  the  former. 

(a)  Central  Sarcoma. — The  great  majority  of  central  sar- 
comata are  of  a  myeloid  nature,  but,  occasionally,  round- 
celled  sarcomata  are  met  with  originating  in  the  centre  of 
the  bone. 

Myeloid  sarcoma  is  frequently  met  with  in  the  lower  jaw, 
and  it  was  here  that  the  disease  occurred  in  the  case  from 
which  Sir  J.  Paget  drew  his  description.  The  case  is  quoted 
by  Mr.  Stanley  (op.  cit.  p.  184)  as  an  example  of  "tumour 
of  bone,  composed  of  a  soft,  very  vascular  substance,  having 
the  characters  of  erectile  tissue,"  but  his  general  description 
corresponds  precisely  to  that  of  Sir  J.  Paget.  Figs,  i  and  2 
of  Plate  13  in  Mr.  Stanley's  atlas  show  the  tumour  in 
situ  and  a  section  of  the  jaw  after  removal.  "The  patient 
was  a  boy  in  St.  Bartholomew's  Hospital,  and  the  growth 
occupied  the  symphysis  of  the  lower  jaw,  and  protruding 
into  the  mouth  presented  a  very  vascular  surface  of  a 
mottled  red  and  purple  colour,  resembling  the  exterior  of 
some  nsevi.  The  tumour  was  not  tender  to  the  touch,  and 
had  not  been  accompanied  by  pain;   it  was  once  destroyed 


MYELOID    SAUCO.MA    01''    TIFE    LOWER    JAW.  661 

by  caustic  to  the  level  of  the  alveolar  border  of  the  jaw,  but 
was  quickly  reproduced  ;  it  was  then  wholly  removed  with 
the  portion  of  the  jaw  in  which  it  originated,  and  the  cure 
was  permanent.  The  morbid  substance  was  found  imbedded 
in  the  cancellous  texture  of  the  jaw ;  it  was  soft,  of  a  dark 
red  colour,  dosel//  rescmUing  the  tissue  of  heaWiy  spleen" 
(Stanley,  p.  185). 

Stanley  mentions  a  case,  very  similar  to  his  own,  recorded 
by  Dupuytren  in  his  Lccons  Orcdcs ;  and  in  the  Museum  of 
St.  Thomas's  there  is  a  very  good  specimen  of  myeloid 
disease,  which  was  described  by  Sir  Astley  Cooper  ("  Surgical 
Essays  ")  as  "  a  fungous  exostosis  of  the  lower  jaw,  which 
formed  a  large  prominence  on  the  chin  "  with  "  purple  fungi 
of  the  gums,"  occurring  in  a  woman,  aged  thirty-two.  The 
preparation  shows  at  the  back  part  a  small  portion  of  firm, 
healthy  bone,  having  a  well-defined  margin  and  not  sending 
out  any  spicula,  from  which  the  tumour  projects.  Around 
its  base  the  tumour  is  covered  with  integument ;  but  in  front 
the  latter  has  ulcerated,  allowing  the  growth  to  fungate 
through  the  ulcerated  aperture. 

A  valuable  preparation  is  in  the  College  of  Surgeons' 
Museum  of  myeloid  tumour  of  the  symphysis  and  body  of 
the  jaw,  removed  by  Mr.  Craven,  of  Hull,  from  a  young 
woman  of  eighteen,  who  made  a  good  recovery  after  the 
operation.  Figs.  144  and  145  show  very  satisfactorily  the 
appearance  of  the  specimen,  which  has  been  divided  hori- 
zontally. The  tumour  was  of  between  two  and  three  years' 
growth,  and  was  covered  with  healthy  mucous  membrane. 
Its  section  shows  a  well-marked  specimen  of  myeloid  disease 
imbedded  between  the  plates  of  the  lower  jaw  ;  its  tissue  is 
of  the  ordinary  friable  character,  resembling  spleen,  but 
somewhat  decolorised  by  immersion  in  spirit,  and  it  is  inter- 
sected by  fibrous  septa.  Two  cysts  may  be  seen  in  the 
section ;  these,  as  mentioned  by  the  late  Mr.  H.  Gray 
(Medico- Ghirujyical  Transactions,  xxxix),  being  of  frequent 
occurrence  in  myeloid  growths.  The  microscopic  examina- 
tion of  Mr.  Craven's  specimen  was  unsatisfactory,  owing 
to  its  previous   immersion  in   spirit,  but  there  can  be  no 


!32 


MALIGNANT    TUMOURS   OF    THE    LOWER    JAW. 


question,  from  the  naked-eye  appearances,  of  the  nature  of 
the  growth. 

In  the  Museum  of  St.  George's  Hospital  are  four  speci- 
mens of  myeloid   disease  affecting  the  lower  jaw,  two  of 

Fig. 144. 


which  have  no  history ;  the  others  were  removed  from  girls 
of  eight  and  five  years  respectively,  of  whom  the  first  was 
known  to  be  well  two  and  a  half  years  afterwards.  In  the 
Museum  of  University  College  are  three  excellent  specimens, 


removed  by  Listen,  and  there  are  three  in  St.  Bartholomew's 
Hospital,  all  from  young  persons. 

A  remarkable,  and  I  believe  unique,  example  of  disease 
of  both  sides  of  the  lower  jaw,  the  microscopic  characters  of 
which  were  decidedly  myeloid,  was  formerly  under  my  own 
care,  of  which  the  following  are  the  brief  particulars.  The 
patient,  a  boy  of  seven  and  a  half,  whose  portrait  is  shown  in 


MYELOIIi    .SARCOMA    OF    THE    LOWER    JAW, 


Fig.  146,  presented  a  remarkable  enlargement  of  both  sides 
of  the  lower  jaw,  giving  his  face  a  very  square  appearance. 
The  affection  had  come  on  gradually  and  painlessly  from  the 
age  of  a  year  and  a  half,  and  at  the  time  I  operated  upon 
him  the  width  of  the  jaw,  as  measured  with  callipers,  was 
five  inches,  the  Avidth  of  an  average  adult  jaw  being  only 
four  inches.  The  growths  were  evidently  projections  from 
the  outer  surfaces  of  the  ancrles  of  the  iaws,  the  inner 
surface  of  the  bone  being  natural,  and  the  mucous  membrane 
of  the  mouth  not  interfered  with.  In  September  and 
October,  1867,  I  removed  the  right  and  afterwards  the  left 
Fig.  146.  Fig. 147. 


tumour  through  incisions  behind  the  margin  of  the  jaw,  and 
without  opening  into  the  mouth.  The  main  part  of  each 
projection  was  sawn  off  the  jaw,  and  are  now  in  the  College 
of  Surgeons'  Museum,  closely  resembling  large  mussel-shells 
filled  with  a  cartilaginous-looking  substance,  which,  however 
(and  especially  some  darker  portions)  gave  distinct  micro- 
scopic evidence  of  myeloid  structure.  A  good  deal  of  this 
material,  which  seemed  to  fill  the  interior  of  the  bone,  was 
gouged  away,  and  the  symmetry  of  the  face  restored  as  far 
as  possible.  The  boy  made  a  good  recovery,  and  Fig.  147, 
from  a  photograph,  shows  his  condition  three  months  after 
the  second  operation,  and  there  appears  to  have  been  no 
tendency  to  recurrence. 


334  MALIGNANT    TUMOUKS    OF    THE    LOWER    JAW. 

Mound-celled  sarcoma  may  begin  in  the  interior  of  the 
bone,  producing  rapid  expansion  of  it,  and  ultimately  break- 
ing through  into  the  mouth,  and  also  through  the  skin  of 
the  face,  if  allowed  to  proceed  unchecked,  A  specimen  in 
University  College  Museum  is  a  good  example  of  the 
disease.  The  morbid  growth  projects  chiefly  on  the  outer 
side,  and  its  most  prominent  part  has  protruded  through 
the  skin,  forming  an  overhanging  nummular  projection  which 
has  an  open  reticular  surface.  On  the  inner  side  the  tumour 
has  invaded  the  jaw,  in  places  destroying  its  entire  thickness ; 
the  growth  however  scarcely  projects  into  the  mouth.  As  seen 
on  the  divided  surface,  it  is  composed  of  a  soft  granular,  yel- 
lowish basis,  supported  and  parted  into  small  polyhedral 
masses  by  narrow  lines  of  fibrous  tissue ;  its  limit  is  every- 
where definable.  Microscopic  examination  shows  the  tumour 
to  have  all  the  characters  of  a  large  round-celled  sarcoma. 

Many  of  the  museum  specimens  hitherto  described  as 
medullary  cancer  are  really  examples  of  round-celled  sarcoma, 
and  the  following  case  of  Mr.  Listen's,  in  the  College  of 
Surgeons,  may  be  quoted  as  an  instance  of  the  size  to  which 
round-celled  sarcoma  may  grow.  "  Part  of  a  lower  jaw, 
including  the  left  condyle,  the  alveolus  of  the  right  first 
molar  tooth,  and  all  the  intermediate  parts  which,  with  an 
enormous  tumour  upon  them,  were  removed  by  operation. 
The  left  ascending  portion  and  side  of  the  jaw,  as  far  as  the 
canine  tooth,  are  completely  enclosed  by  the  tumour,  and  it 
covers  both  surfaces  of  the  jaw  as  far  as  the  right  canine 
tooth.  A  round  lobulated  mass  projects  downwards  and 
forwards,  and  in  the  opposite  direction  the  tumour  projects 
into  the  mouth  with  a  rough  fungous  surface,  in  which  a 
displaced  molar  tooth  is  seen.  The  interior  of  the  tumour  is 
indistinctly  lobulated,  composed  of  round  masses  connected 
by  cellular  tissue,  and  of  a  soft  texture ;  it  is  invested  by  a 
thick  capsule." 

I  had  under  my  care  an  interesting  case  of  round-celled 
sarcoma  of  the  lower  jaw,  in  a  little  girl,  aged  five — one  of 
a  numerous  and  healthy  family,  who  was  in  perfect  health 
until  seven  weeks    before   I   saw  her.      The   mother   then 


KOUND-CELLED    SARCOMA   OF    THE  LOWER    JAW.        33o 

noticed  that  the  second  temporary  molar  tooth  on  the  right 
side  was  loose,  and  the  gum  swollen;  and  a  tumour  de- 
veloped so  rapidly,  that  when  I.  saw  her  the  side  of  the  face 
was  considerably  enlarged,  and  a  large  fungous  mass  pro- 
truded into  the  mouth.  On  Sept.  loth,  1867,  I  removed 
the  right  side  of  the  jaw  from  close  to  the  symphysis  to  the 
articulation,  and  the  preparation  is  now  in  the  Museum  of 
the  College  of  Surgeons.  The  structure  of  the  growth  was 
distinctly  medullary.  The  child  made  a  perfect  recovery, 
and  was  well  for  six  weeks,  when  a  small  growth  was 
noticed  within  the  cheek,  which  made  such  rapid  progress 
that  in  four  days,  when   she  was  brought  up  to  me  again. 

Fig.  148. 


there  was  a  tumour  filling  the  cheek,  and  involving  the 
remaining  portion  of  the  jaw  as  far  as  the  canine  tooth,  and 
a  fungus  had  been  thrown  out  through  a  portion  of  the  old 
cicatrix. 

On  Oct.  26th,  1867,  I  removed  the  whole  of  the  disease 
again,  cutting  the  jaw  on  the  left  side  immediately  in  front 
of  the  second  molar  tooth,  and  removing  the  whole  of  the 
skin  involved  in  the  fungus.  The  patient  made  a  good 
recovery,  and  Fig.  148,  drawn  from  a  photograph  taken 
seven  weeks  after  the  second  operation,  shows  her  then 
condition,  which  was  quite  satisfactory,  there  being  no 
evidence  whatever  of  return,  and  very  slight  deformity 
considering  the  amount  of  jaw  removed. 

The  second  growth,  which  was  even  more  markedly  me- 
dullary than  the  first,  is  preserved  with  it. 


336  MALIGNANT    TUMOUES    OF    THE    LOWEE    JAW. 

The  child  continued  in  perfect  health  to  the  end  of  the 
year,  but  early  in  January,  1868,  the  disease  reappeared, 
both  at  the  symphysis  and  in  the  masseteric  region  on  both 
sides.  Coupled  with  this  there  was  loss  of  appetite,  great 
exhaustion,  and  irritability  of  the  system  ;  and  the  poor 
child  gradually  sank,  and  died  on  Feb.  9th,  a  little  more 
than  six  months  after  the  first  appearance  of  the  disease. 

This  case  appears  to  me  of  considerable  interest,  since 
it  shows  the  advantage  of  surgical  interference,  even  under 
desperate  circumstances.  If  the  first  growth  had  not  been 
removed,  the  patient  would  have  been  shortly  destroyed  by 
the  fungus  in  the  mouth,  whereas  the  operation  gave  her 
six  weeks'  immunity  from  suffering.  The  return  of  the 
disease  was  of  such  a  rapid  nature,  that  it  would  in  a  very 
few  days  have  destroyed  the  patient  by  haemorrhage  from 
the  fungus  which  had  already  begun  to  form  in  the  skin  ; 
but  the  second  operation  again  relieved  her,  and  restored 
her  to  comfort  and  apparent  health  for  more  than  two 
months.  When  the  disease  finally  appeared  on  both  sides 
of  the  face,  it  was  obviously  beyond  surgical  control,  and 
rapidly  destroyed  the  patient.  The  relief  which  the  oper- 
ations afforded  was,  however,  gratefully  acknowledged  by  the 
friends  of  the  little  patient. 

(b)  Periosteal  Sarcoma. — This  variety  of  growth  appears 
in  two  forms ;  the  spindle-celled  sarcoma  and  the  more 
malignant  round-celled,  medullary,  or  encephaloid  sarcoma. 

Spindle-celled  Sarcoma This  frequently  attacks  the  lower 

jaw,  and  may  prove  fatal,  by  obstruction  either  to  respira- 
tion or  deglutition,  if  allowed  to  grow  unchecked  for  many 
years. 

Sir  Philip  Crampton's  description  of  the  whole  course 
of  the  disease,  as  witnessed  in  the  jaw,  is  so  perfect  that 
I  cannot  do  better  than  reproduce  it :  "  The  first  indication 
of  this  formidable  disease  is  the  appearance  of  merely  a 
small  swelling  or  projection  of  the  gum,  between  two 
of  the  teeth.  The  teeth,  however,  soon  become  loose  and 
dislocated,  being  forced  inwards  upon  the  tongue,  or  out- 
wards aaainst  the  cheek  ;  as  the  tumour  enlarges  it  assumes 


SPINDLE- CELLED    SARCOMA    OF    THE    LOWER    JAW.       337 

a  tuberciilated  appearance,  the  tubercules  varying  in  colour 
from  a  light  pink  to  a  deep  purple  ;  they  are  firm  in  struc- 
ture, perfectly  indolent,  and  do  not  readily  bleed  even  when 
roughly  handled.  As  the  morbid  growth  extends  in  all 
directions,  the  mouth  is  soon  filled  by  the  tumour,  the  lower 
jaw  is  forced  downwards  upon  the  fore  part  of  the  neck, 
the  tongue  is  pushed  backwards  into  the  pharynx,  the  mouth 
is  carried  to  the  side  of  the  face  opposite  to  the  tumour, 
and  before  the  patient  sinks  under  his  sufferings,  a  tumour 
is  sometimes  formed  which  nearly  equals  the  bulk  of  the 
head  itself.  It  is  gratifying,  however,  to  be  able  to  state 
that  even  under  such  deplorable  circumstances  life  has 
been  preserved,  and  the  hideous  deformity  removed  by  an 
operation  which  must  be  considered  as  one  of  the  boldest 
and  most  successful  of  which  modern  surgery  has  to  boast. 
But  it  is  from  the  internal  structure  of  osteo-sarcomatous 
tumours,  as  developed  in  the  course  of  operations  under- 
taken for  their  removal,  or  by  dissection  after  death,  that 
the  true  and  distinctive  characters  of  these  affections  are  to 
be  traced.  In  the  benign  form  of  osteo-sarcoma,  the  local, 
and,  I  might  almost  say,  the  encysted  character  of  the 
disease  is  evinced  by  the  distinct  line  which  separates  the 
morbid  growth  from  the  soft  parts  with  which  it  is  in  con- 
tact. It  becomes  apparent  that,  as  the  tumour  has 
enlarged,  it  has  pushed  the  soft  parts  before  it,  or  in- 
sinuated itself  into  their  interstices,  and  that,  so  far  from 
becoming  incorporated  with  the  surrounding  structares,  and 
assimilating  them  to  its  own  nature  (as  invariably  happens 
in  the  advanced  stage  of  malignant  tumours),  it  has  formed 
attachments  so  slight,  that  when  the  portion  of  bone  from 
whence  the  tumour  springs  is  detached,  the  whole  morbid 
growth  may  be  (as  it  were)  drawn  out  from  the  surrounding 
parts  almost  without  the  aid  of  the  knife.  The  interior 
of  the  tumour  presents  a  great  variety  of  structure,  but  I 
should  say,  in  general,  that  the  cartilaginous  character 
which  the  tumour  exhibits  in  its  origin  prevails  to  the  last. 
In  the  early  stages  of  the  disease  the  tumour  consists  of 
a    dense    elastic    substance,    resembling    fibro-cartilaginous 

Y 


338  MALIGNANT    TUMOUKS    OF    THE    LOWER   JAW. 

structure,  but  the  resemblance  is  more  in  colour  than  in 
consistency,  for  it  is  not  nearly  so  hard,  and  is  granular 
rather  than  fibrous^  so  that  it  '  breaks  short.'  On  cutting 
into  the  tumour  the  edge  of  the  knife  grates  against  spicula 
or  small  grains  of  earthy  matter,  with  which  its  substance 
is  beset.  If  the  tumour  acquires  any  considerable  size,  it 
is  usually  found  to  contain  cavities  filled  with  fluids  differ- 
ing in  colour  and  consistency,  but  in  general  the  fluid  is 
thickish,  inodorous,  and  of  the  colour  of  chocolate.  Some- 
times the  growth  of  the  tumour,  or  the  secretion  of  fluid 
within  its  substance,  is  so  slow  that  the  deposition  of  bony 
matter  keeping  pace  with  the  absorption,  the  bone  becomes 
expanded  into  a  large  and  thick  bony  case,  in  which  the 
tumour  is  completely  enclosed.  There  is  a  beautiful  pre- 
paration of  this  form  of  the  disease  in  the  Museum  of  the 
Eoyal  College  of  Surgeons.  But  in  general  the  walls  of 
the  cavity  consist  of  cartilaginous  structure  mixed  with 
bone,  the  bone  bearing  but  a  small  proportion  to  the  carti- 
lage. The  extent  to  which  this  description  of  tumour  may 
increase  without  materially  affecting  the  general  health,  is 
one  of  the  most  extraordinary  circumstances  connected  with 
its  history"  (p.  54 1). 

The  '  cartilaginous '  appearance  here  referred  to,  relates 
only  to  the  naked-eye  appearance  of  the  structure,  which  is 
characteristically  said  to  '  break  short.'  Microscopic 
examination,  as  I  have  had  the  opportunity  of  observing 
in  a  large  tumour  of  the  kind,  shows  a  dimly  granular 
stroma,  closely  resembling  the  matrix  of  cartilage,  but  con- 
taining no  true  cartilage-cells.  Though  parts  of  the  tumour 
may  show  structure  of  this  kind,  the  greater  part  is  usually 
of  a  distinctly  spindle-celled  character. 

In  1828  Mr.  Syme  removed  a  very  large  tumour  of 
this  description  (probably  the  largest  which  has  ever  been 
removed),  weighing  4^1bs.,  which,  no  doubt,  for  the  reason 
given  above,  he  refers  to  in  a  lecture  published  in  the 
Lancet,  February  3rd,  1855,  as  a  fibro-cartilaginous  tumour. 
The  patient  made  a  good  recovery,  and  the  accompanying 
illustrations,  Figs.  149  and  150,  for  which  I  was  indebted 


SPINDLE-CELLED    SAKCOMA    OF   THE    LOWER    JAW.       339 

to  Mr.  Syme,  show  his  condition  before  and  some  years 
after  the  operation,  which  was  one  of  the  earliest  of  the 
kind  in  this  country. 

The  spindle-celled  sarcoma  will,  if  its  surface  be  irritated 
by  caustics,  &c.,  throw  out  fungus  masses.  Mr.  Cusack 
(loc.  cit.)  gives  an  example  of  this  result  occurring  from 
sloughing  of  the  skin  of  the  face,  due  to  over-distension  by 
the  tumour.  Occasional  haemorrhage  from  such  surfaces 
led    to  these   cases  beinsc  massed  together  with  cancer  as 


Fig.  149. 


Fig.  150. 


examples  of  fungus  hmmatodes,  and  doubtless  Sir  William 
Tergusson's  observation  is  correct,  that  the  rarity  of  fungus 
hsematodes  in  the  present  day,  is  due  to  the  early  treatment 
to  which  cases  of  this  kind  are  submitted. 

Under  the  head  of  Spindle-celled  Sarcoma  must  be 
included  the  following  two  cases,  which  were  originally 
classed  as  *  recurrent  fibroid.' 

The  first  occurred  in  the  Westminster  Hospital,  under 
the  care  of  Mr.  Holt,  in  1858,  in  a  young  woman,  aged 
eighteen,  who  had  a  soft  fungoid  mass  covering  the  molar 
teeth  of  the  right  side  of  the  lower  jaw,  of  ten  weeks' 
duration.     It  apparently  sprang  from  the  angle  of  the  jaw,. 


340  MALIGNANT    TUMOURS    OF    THE    LOWER   JAW. 

or  the  base  of  the  ascending  ramus,  and  had  pushed  the 
mucous  covering  before  it.  The  molar  teeth  were  firmly 
fixed  i]i  their  sockets  ;  the  wisdom  tooth  was  covered  with 
gum.  The  rapid  growth  of  the  fungus,  and  the  absence  of 
any  material  pain,  led  to  the  conclusion  that  it  was  probably 
a  form  of  epulis  of  a  malignant  type.  Mr.  Holt  therefore 
thought  it  advisable  to  remove  the  whole  mass,  and  examine 
the  bone  prior  to  removal  of  the  jaw  itself.  This  being 
done,  its  attachments  were  found  to  be  connected  with  the 
posterior  part  of  the  body  and  anterior  part  of  the  ascending 
ramus,  the  bone  being  hard  and  of  its  ordinary  density.  Mr. 
Holt  did  not  feel  warranted  in  doing  that  which  he  was 
prepared  to  do — namely,  remove  the  bone  at  its  articulation 
at  this  time — but  preferred  removing  with  the  cutting  pliers 
all  the  bone  to  which  the  growth  had  been  attached.  Mr. 
Clendon  having  then  extracted  the  molars  and  wisdom  tooth, 
Mr.  Holt  cut  through  half  the  thickness  of  the  jaw  corre- 
sponding to  those  teeth,  and,  going  further  back,  included  the 
coronoid  process,  with  more  than  half  of  the  sigmoid  notch. 
The  disease  was  found  to  be  intimately  connected  with  the 
periosteum,  which  readily  peeled  off,  leaving  the  bone  some- 
what roughened.      (See  Lancet,  Jan.  28th,  1858.) 

The  disease  reappeared  in  a  few  weeks,  when  Mr.  Holt 
was  compelled  to  remove  it  again,  including  this  time  the 
remaining  part  of  the  ramus  of  the  jaw.  The  disease  now 
was  not  confined  to  the  covering  of  the  bone,  but  extended 
into  the  pharynx,  and  was  evidently  attached  to  the  mucous 
lining  of  the  whole  of  one  side  of  the  mouth. 

The  poor  girl  left  the  hospital  and  went  to  Eeading,  and 
died  on  the  3rd  of  February.  An  autopsy  was  performed 
by  Mr.  Walford,  the  particulars  of  which  are  given  in  his 
own  words : 

"  Fanny  S died  on  the  3rd,  and  assisted  by  Mr.  G. 

May,  jun.,  and  Mr.  Fernie,  I  made  a  post-mortem  examina- 
tion. I  did  not  open  the  head.  The  thoracic  and  abdo- 
minal viscera  were  free  from  disease.  I  dissected  out  the 
tumour,  which,  had  the  whole  of  it  been  there,  would  have 
completely  encircled  one  side  (one-half)  of  the  lower  jaw ; 


SPINDLE-CELLED    SARCOMA    OF    THE   LOWER   JAW.       341 

it  extended  up  to  the  zygomatic  arch  and  downward  into 
the  neck.  The  gullet  was  free,  and  it  evidently  grew  into, 
not  from,  the  pharyngeal  region.  We  could  not  satisfac- 
torily discover  its  origin.  The  portion  of  lower  jaw-bone 
left  after  the  operation  was  sawn  through  at  the  symphysis, 
and  exhibits  the  margins  of  the  tumour  on  the  periosteum, 
which,  I  think,  must  be  considered  the  starting-point,  and 
that,  as  regards  treatment,  would  be  practically  the  bone." 
(See  Lancet,  March  6th,  1858.) 

The  second  case  occurred  at  the  Great  ISTorthern  Hos- 
pital, in  the  practice  of  Mr.  George  Lawson,  who  performed 
three  operations  with  the  hope  of  eradicating  the  disease, 
which,  however,  eventually  proved  fatal,  as  in  the  preceding 
instance.  The  patient  was  a  young  woman,  aged  seventeen, 
and  the  first  operation  was  performed  October  4th,  1858. 
She  had  then  what  might  be  termed  a  large  epulis  growing 
from  the  anterior  and  inner  surface  of  the  ascending  ramus 
of  the  lower  jaw  on  the  left  side,  extending  from  a  point 
near  the  angle  to  close  upon  the  condyle.  Mr.  Lawson  re- 
moved the  tumour  with  bone-forceps,  cutting  away  appa- 
rently all  its  bony  attachments.  About  six  weeks  after  the 
first  operation  a  small  elastic  mass  appeared  in  the  temporal 
fossa  of  the  affected  side,  but  the  jaw  was  apparently  free. 
This  Mr.  Lawson  excised,  but  found  that  the  growth  had 
evidently  sprung  from  its  original  site,  and  extending 
upwards,  had  passed  beneath  the  zygoma  into  the  temporal 
fossa.  The  third  operation  was  in  June,  1859,  when,  in 
consequence  of  the  great  size  the  tumour  had  attained,  the 
inability  of  the  girl  to  open  her  mouth,  and  the  great  diffi- 
culty she  experienced  in  deglutition,  Mr.  Lawson  removed  a 
portion  of  the  inferior  maxilla,  sawing  through  the  bone  in 
front  of  the  angle,  and  then  disarticulating.  Upon  the 
removal  of  this  portion  of  bone  (Fig.  151),  it  was  found 
that  the  tumour  had  formed  so  many  attachments  to  the 
periosteum  of  the  bones  forming  the  base  of  the  skull,  that 
the  operator  was  compelled  to  leave  some  of  the  disease 
behind. 

By  the  end  of  November,    1859,  the   tumour   had   again 


342 


JIALIGNANT    TUMOURS    OF    THE    LOWER   JAW. 


grown  to  a  large  size,  and  from  the  space  it  occupied  in  her 
mouth  interfered  much  with  her  taking  nourishment.  It  now 
began  to  soften  and  to  ulcerate  on  its  surface,  both  externally 
and  within  the  mouth,  and  occasionally  very  alarming 
haemorrhages  would  take  place,  so  as  to  threaten  imme- 
diate dissolution,  but  from  all  these  she  rallied ;  within  the 
mouth  large  sloughs  would  occasionally  separate,  allowing 
her  to  recruit  her  health  by  enabling  her  to  take  additional 
nourishment.  She  died  early  in  1 860,  worn  out  and  greatly 
emaciated.  The  drawing  (Fig.  1 5  2),  for  which  I  am  indebted 
to  Mr.  Lawson,  shows  the  terrible  deformity  as  seen  after 
death.  The  preparation  is  in  the  Museum  of  the  College  of 
Surgeons.     (See  Pathological  Society's  Transactions,  vol.  xi.) 

Fig.  151. 


JRound-celled  sarcoma  may  commence  in  the  periosteum 
and  is  much  more  malignant  than  the  spindle-celled  variety. 
The  cases  formerly  described  as  medullary  cancer  are  really 
round-celled  sarcomata. 

Both  in  spindle-celled  and  round-celled  sarcomata  carti- 
lage cells  may  be  present,  or  even  bone  may  be  deposited. 
We  thus  get  two  mixed  varieties,  the  chondro-sarcoma 
and  the  osteo-sarcoma. 

Chondrosarcoma  is  characterised  by  rapidity  of  growth 
and  by  early  recurrence  after  removal.  The  primary  tumour 
is  mainly  enchondroma,  but  the  recurrent  growths  are  chiefly 
composed  of  small  round-celled  sarcoma,  which  tend  to  pro- 
duce internal  deposits  through  the  vascular  system. 

The  following  good  illustration  of  the  disease  occurred 
under  my  own  care.     A  woman,  aged  forty-four,  was  ad- 


CHONDKO-SAECOMA    OF   THE    LOWER   JAW, 


343 


mitted  into  University  College  Hospital  on  April  i  ith,  1877, 
with  the  following  history  :  She  first  noticed  a  swelling 
connected  with  the  left  side  of  the  lower  jaw,  nine  months 
before.     The    swelling    was    painful,  and  accompanied  by 

Fig.  152. 


numbness  over  the  chin.  Twenty  years  before  she  had 
received  a  violent  blow  over  the  jaw,  when  attendant  in  a 
lunatic  asylum.  The  family  history  threw  no  light  on  the 
case.     The  patient  had  always  enjoyed  good  health. 

On  admission,  there  was  a  large  tumour  over  the  leftside 
of  the  lower  jaw,  and  firmly  connected  with  the  inner  and 
outer  surfaces  of  the  bone,  extending  from  an  inch  behind 


344 


MALIGXAis^T   TUMOUES    OF    THE    LOWEE    JAW, 


the  symphysis  to  the  angle.  The  growth  generally  was  firm 
and  elastic,  though  some  parts  were  much  softer  than  others. 
The  border  of  the  tumour  was  well  defined,  and  the  skin  was 
freely  movable  over  it.  A  nodule,  the  size  of  a  walnut, 
projected  between  the  teeth  into  the  cavity  of  the  mouth. 
The  patient  complained  of  shooting  pains  in  the  tumour, 
which  ran  along  the  lower  lip.      There  was  no  enlargement  of 

Fig. 153. 


lymphatic  glands,  and  no  other  tumour.  The  general  health 
was  good.     The  patient's  appearance  is  shown  in  Fig.  153. 

On  April  14th  I  removed  the  tumour  with  the  bone  in- 
volved, from  the  left  of  the  symphysis  to  an  inch  above  the 
angle,  and  the  patient  made  a  good  recovery. 

Eleven  weeks  after  discharge  she  was  re-admitted.  The 
lower  borders  of  the  segments  of  the  previously  divided  jaw 
had  united  by  fibrous  tissue,  but  a  V-shaped  notch  existed 
at  the  upper  border  large  enough  to  admit  the  tip  of  the 
finger.  Eecurrence  of  the  growth  had  taken  place  in  con- 
nection with  both  sections  of  bone.  There  was  a  tumour  as 
large  as  a  hen's  egg  beneath  the  chin,  but  this  could  not  be 


-    CHONDKO-SAECOMA    OF    THE    LOWEE    JAW.  345 

felt  through  the  mouth,  whilst  a  second  and  larger  one 
caused  bulging  of  the  left  cheek,  and  was  mainly  situated 
over  the  ramus  of  the  jaw  ;  it  projected  into  the  oral  cavity 
and  rendered  articulation  indistinct,  although  there  was  no 
difficulty  in  deglutition.  The  skin  was  freely  movable  over 
both  masses  ;  there  was  merely  a  linear  cicatrix  at  the  site 
of  the  old  incision.  The  lymphatic  glands  were  not  en- 
larged, and  the  general  health  was  good. 

A  second  operation  was  done  on  August  ist,  1877.  It 
being  found  impossible  to  remove  the  tumour  by  the  mouth, 
I  made  an  incision  along  the  lower  border  of  the  jaw, 
from  two  inches  to  the  right  of  the  symphysis  for  a 
distance  of  six  inches.  The  lower  lip  was  dissected  from 
the  bone  and  turned  upwards,  and  the  jaw  sawn  through 
at  the  symphysis,  which  allowed  a  piece  on  the  left  to  be 
removed  with  growth  attached.  It  was  found  that  the 
whole  of  the  posterior  mass  could  not  be  removed,  as  it 
extended  deeply  into  the  pterygoid  region,  so  after  enu- 
cleating as  much  as  possible,  the  operation  was  not  further 
proceeded  with.  The  wound  was  syringed  out  with  strong 
solution  of  chloride  of  zinc,  and  then  plugged  with  lint. 

For  the  first  fourteen  days  the  wound  continued  to  heal 
rapidly,  but  at  this  time  it  commenced  to  fungate,  and  on 
the  twentieth  day  sharp  bleeding  ensued,  which  required  the 
actual  cautery  to  arrest  it.  Severe  pain  was  more  or  less 
constant,  and  the  discharge  very  foetid.  On  the  28  th  the 
fungating  mass  reached  the  clavicle,  and  completely  hid  the 
left  side  of  the  neck  ;  haemorrhage  again  occurred,  and  the 
cautery  was  employed. 

In  spite  of  a  supporting  plan  of  treatment  the  general 
health  rapidly  failed,  the  patient  fell  into  a  semi-comatose 
condition,  got  more  and  more  asthenic  and  cachectic,  and 
died  on  the  forty-third  day  after  the  second  operation. 

Autopsy. — The  mass  of  growth  extended  from  the  zygoma 
downwards  for  over  seven  inches,  and  was  from  five  to  six 
inches  in  thickness.  Another  tumour  sprang  from  the  right 
segment  of  the  divided  jaw,  and  the  left  side  of  the  tongue 
and  floor  of  the  mouth  were  largely  invaded.     The  upper 


346  MALIGNANT    TUMOURS    OF    THE   LOWER   JAW. 

jaw  was  not  involved,  but  only  imbedded  in  the  growth, 
which  had  forced  itself  deeply  amongst  the  neighbouring 
parts,  where  the  veins  were  filled  with  firm  white  clots,  but 
no  growth  had  sprung  up  in  connection  with  their  walls. 
The  tumour,  on  section,  varied  in  colour,  being  yellowish- 
white  in  some  parts,  whilst  it  was  red  and  vascular  in  others, 
and  mottled  with  patches  of  extravasated  blood.  It  weighed 
2lb,  30Z.  There  were  two  nodules  of  secondary  growth  in 
the  left  lung,  and  three  larger  ones  in  the  right  lung.  One 
of  these  was  distinctly  seen  to  be  lying  in  the  course  of  a 
good- sized  branch  of  the  pulmonary  artery,  whose  walls 
were  expanded  over  it.  It  did  not  completely  block  the 
lumen  of  the  vessel,  and  on  its  surface  was  a  white  fibrinous 
deposit. 

The  mass  removed  at  the  first  operation  consisted  chiefly 
of  enchondroma,  with  a  dim  hyaline  and  fibrous  matrix, 
but  interspersed  with  islets  of  round-celled  sarcoma.  The 
recurrent  masses  were  made  up  chiefly  of  round  and  spindle- 
celled  sarcoma,  whilst  scattered  throughout  were  isolated 
portions  of  cartilaginous  tissue,  with  fibrous  matrix. 

One  of  the  cases,  described  in  the  chapter  on  simple 
tumours  of  the  lower  jaw,  as  pure  enchondroma,  is  really  a 
chondro-sarcoma  with  a  very  low  degree  of  malignancy.  In 
that  case  there  were  no  internal  recurrences  as  in  the  case 
just  described  (p.  325). 

Ossifying  sarcoma,  in  which  ossification  takes  place  exten- 
sively in  a  matrix  of  sarcomatous  tissue,  occurs  in  the 
lower  jaw,  and,  as  in  the  following  case,  presents  at  first 
most  of  the  characters  of  an  ordinary  osteoma.  Fig.  154 
shows  the  portion  of  lower  jaw  at  first  removed,  with  a 
section  of  the  tumour,  which  it  is  difiicult  to  distinguish 
from  ordinary  bone,  except  by  the  striation  seen  best  at  its 
margins.  The  rapid  recurrence  of  the  disease  in  a  soft  form 
showed  the  true  nature  of  the  case,  and  the  patient  died 
exhausted  within  a  year  of  the  first  operation. 

W.  G ,    aged    fifty,    was    admitted  into  University 

College  Hospital  on  May  9th,  1 8  8 1 .  About  five  months 
previously    he    noticed    a    pricking    pain    about    the    left 


OSSIFYING    SARCOMA    OF    THE    LOWER    JAW.  347 

side  of  the  lower  jaw,  and  soon  a  lump  appeared  outside 
the  bicuspid  teeth  ;  it  grew  steadily  but  slowly,  until  one 
month  before  admission.  At  this  time  the  patient  had 
several  teeth  extracted,  and  the  increase  in  the  size  of  the 
growth  became  rapid  after  this  interference ;  there  was 
constant  gnawing  pain.  The  patient  believed  exposure  to 
cold  to  have  been  the  cause  of  the  swelling.  Both  his 
parents  died  of  old  age,  and  had  no  kind  of  tumour. 

On  admission  the  lower  part  of  the  left  cheek  was  bulged 
outwards   considerably  by  a  very  hard  rounded    swelling, 

Fig.  154. 


which  covered  the  outer  side  of  the  left  half  of  the  lower  jaw 
from  a  short  distance  in  front  of  the  angle  almost  to  the  left 
canine ;  the  lower  edge  of  the  bone  was  concealed  by  slight 
projection  of  the  mass  below  it ;  and,  on  pressing  upwards  in 
the  sub-maxillary  region,  a  considerable  swelling  could  be 
felt  on  the  inner  side  of  the  bone.  Altogether  the  impres- 
sion conveyed  to  the  fingers  was  that  the  growth  was 
central,  and  that  the  so-called  expansion  of  bone  had 
occurred  over  it.  No  teeth  were  present  on  the  left  side 
behind  the  canine,  the  alveolus  was  widened,  and  presented 
posteriorly  several  low,  rounded  swellings,  covered  by 
mucous  membrane,  soft  or  even  cystic ;  whilst  in  front  lay  a 
large  crater-like  ulcer,  at  the  bottom  of  which  no  bone  was 


348  MALIGNANT   TUMOURS    OF    THE    LOWER    JAW. 

bare.  The  tongue  and  floor  of  the  mouth  were  normal.  A 
small,  not  tender,  gland  could  be  felt  behind  the  angle  of  the 
jaw.  There  was  moderate  constant  pain  in  the  part,  much 
increased  by  hanging  the  head  down.  As  regards  general 
health  there  was  nothing  to  be  desired. 

On  May  1 1  th  ether  was  given,  and  the  growth  removed 
by  an  incision  from  the  left  angle  to  the  symphysis  ;  the  jaw 
was  sawn  through  to  the  left  of  the  symphysis,  the  soft  parts 
stripped  from  the  growth,  and  then  the  bone  was  divided 
near  the  angle.  The  wound  was  closed  by  wire  sutures. 
and  dressed  with  cotton  wool. 

The  wound  was  all  but  healed  on  the  eighth  day,  quite  so 
on  the  twentieth,  when  the  man  left  the  hospital  feeling  quite 
well. 

The  growth  was  smooth  on  the  surface,  and  covered  by  a 
thin  layer  of  fibrous  tissue  ;  it  was  sub-periosteal,  not  central, 
and  on  the  inner  side  of  the  jaw  lay  two  long  oval  masses, 
parallel  to  the  mylo-hyoid  ridge — one  above,  one  below  it. 
A  section  of  the  large  outer  mass  showed  it  to  consist  of 
solid  bone,  much  denser  than  ordinary  cancellous  tissue, 
surrounded  by  a  margin  of  soft  greyish-yellow  tissue, 
nowhere  more  than  a  quarter  of  an  inch  thick.  Vertical 
striation  was  plain  in  this  border,  and  was  in  part  due  to 
spicules  of  bone.  On  the  alveolar  border  was  a  layer  of 
similar  soft  growth,  one-third  to  half  an  inch  thick.  Micro- 
scopically the  growth  consisted  of  rather  large  round  and 
polygonal  cells,  surrounded  by  bands  of  spindle  cells,  and 
tracts  of  fairly  developed  connective  tissue  ;  so  that  to  the 
naked  eye  a  section,  seen  by  transmitted  light,  was  made 
up  of  distinct  lobules.  The  above  description  refers  to  the 
thin  soft  layer  on  the  surface,  and  even  in  its  substance  dots 
of  bone  were  numerous ;  whilst  at  its  base  lay  a  large  mass 
of  deep  yellow  bone,  fairly  dense,  having  large  lacunae  and 
ill-developed  canaliculi ;  tumour  cells  occupied  the  cancellous 
spaces. 

Soon  after  leaving  the  hospital  the  patient's  face  swelled 
a  good  deal,  and  it  was  thought  that  recurrence  of  the 
growth   had   occurred ;    but  a  sequestrum  worked  out,  and 


OSSIFYING    SAECOMA    OF    THE   LOWER    JAW.  349 

the  swelling  subsided.  In  three  months,  however,  he  was 
re-admitted,  having  had  a  distinct  recurrence  for  six  weeks, 
with  much  constant  pain.  His  health  was  still  very- 
good. 

On  September  6th,  1 88 1,  the  left  side  of  the  face  was  now 
swollen  from  two  inches  below  the  line  of  the  jaw  to  above 
the  level  of  the  ala  nasi,  and  from  the  symphysis  to  the 
lower  end  of  the  ramus  of  the  jaw.  On  looking  into  the 
mouth,  two  large  firm  masses  of  growth  were  found — one 
above  the  old  scar,  lying  in  the  cheek,  and  running  back 
almost  to  the  anterior  pillar  of  the  fauces  ;  the  other,  below 
the  scar,  occupied  the  floor  of  the  mouth.  They  were 
separated  by  a  deep  groove,  at  the  bottom  of  which 
was  a  little  ulceration ;  elsewhere,  the  surfaces  of  the 
growths  were  slightly  lobulated  and  covered  by  mucous 
membrane. 

No  large  glands  were  felt.  On  the  following  day  the 
whole  of  this  mass,  together  with  the  ramus,  coronoid  pro- 
cess, and  condyle  of  the  jaw,  were  removed  by  the  ordinary 
incision  for  the  removal  of  half  the  lower  jaw. 

The  patient  again  recovered,  without  any  bad  symptoms. 
The  hinder  part  of  the  wound  gaped  widely,  but  it  was 
healing  steadily,  and  there  was  no  obvious  recurrence  on 
October  8th,  when  the  patient  left  the  hospital. 

The  left  angle  and  ramus  of  the  jaw  were  surrounded  on 
all  sides  by  masses  of  new  growth,  in  which  there  was  very 
little  bone,  as  far  up  as  the  base  of  the  coronoid  process. 
In  the  mass  which  lay  below  the  scar,  unconnected  with  the 
jaw,  there  was  a  large  proportion  of  bone.  Microscopically, 
the  growth  was  very  similar  to  the  primary  one ;  there 
was  less  division  into  lobules,  and  the  cells  were, 
perhaps,  smaller  ;  the  bits  of  bone  seen  were  much  less 
perfect. 

On  January  30th,  1882,  the  patient  was  again  admitted, 
having  noticed  a  recurrence  of  the  growth  two  months.  The 
left  cheek  was  now  enormously  swollen,  and  the  angle  of  the 
mouth  pushed  forwards  by  a  mass  of  new  growth,  fungating 
into  the  mouth  along  the  line  of  the  jaw,  but  elsewhere 


350  MALIGNANT  TUMOUES    OF    THE   LOWER   JAW. 

covered  by  mucous  membrane.  The  old  wound  was  healed, 
but  for  an  ulcer  one  inch  and  a  half  by  half  an  inch,  round 
which  there  was  a  good  deal  of  firm  infiltration  at  its 
posterior  end.  The  growth  was  firm  and  elastic  at  some 
points,  bony  at  others,  adherent  to  the  symphysis,  but  not 
very  firmly.  The  whole  face  was  cedematous  ;  the  left  tem- 
poral fossa  rather  full,  and  the  seat  of  much  pain.  The  man 
was  still  pretty  strong. 

On  February  2nd  the  old  incision  was  opened  up,  and  the 
main  part  of  the  growth  turned  out.  As  the  skin  was 
stripped  up,  the  hair-bulbs  could  be  seen  springing  out  of 
the  tumour ;  then  a  piece  in  the  floor,  on  either  side  of  the 
frsenum,  was  removed,  and  the  two  ranine  arteries  cut  and 
tied.  When  the  tongue  had  been  drawn  forwards  by  a 
string,  the  symphysis  was  removed  to  just  beyond  the  right 
canine  tooth ;  and,  finally,  an  attempt  was  made  to  remove 
the  posterior  end  of  the  tumour,  but,  as  it  here  seemed  to 
involve  the  tonsil  and  carotid  vessels,  and  to  spread  into  the 
temporal  fossa,  much  had  to  be  left. 

Again  the  patient  made  a  good  recovery.  The  anterior 
part  of  the  wound  healed,  but  the  posterior  gaped  widely, 
and  he  went  out  with  a  large  hole  here.  Pain  in  the  temporal, 
region  continued.  He  died  at  home  on  April  5  th,  having 
been  able  to  walk  up  and  down  stairs  to  the  last.  The 
total  duration  of  the  disease  would,  therefore,  seem  to  have 
been  about  seventeenth  months.  A  section  from  the  second 
recurrence  was  more  densely  round-celled  than  either  of  the 
preceding  specimens  ;  slight  traces  of  lobulation  remained, 
and  there  was  a  large  amount  of  rudimentary  bone.  Through- 
out the  vessel-walls  were  formed  by  cells  of  the  new 
growth. 

2.  Carcinoma. — Carcinoma  occurs  in  the  lower  jaw  in 
two  forms,  the  columnar  and  the  squamous  epithelioma. 

Columnar  epithelioma  has  already  been  described  in  one 
form  in  connection  with  multilocular  cysts  of  the  lower  jaw. 
One  case  at  least,  has  been  described  in  which  the  growth 
had  a  distinct  columnar  structure  without  the  characteristic 
formation  of  cysts.      Eor  the  elucidation  of  the  epithelioma- 


COLUMNAR    EPITHELIOMA    OF    THE    LOWER    JAW. 


151 


tous  nature  of  this  case  I  am  indebted  to  Mr.  Eve,  to  whose 
lecture  on  Cysts  of  the  Lower  Jaw  reference  has  ah^eady 
been  made  (p.  198). 

The  appearance  of  this  tumour  is  shown  in  Kg.  155, 
taken  from  a  photograph. 

The  enormous  size  of  the  tumour  can  be  best  appreciated 
by  the  drawing,  the  measurements  being  as  follows  :   From 

Fig.  r55. 


the  lobule  of  one  ear  round  the  chin  to  the  lobule  of  the 
other  was  19^  inches  ;  from  the  edge  of  the  lower  lip  over 
the  chin  to  the  pomum  Adami  1 3  inches ;  and  the  width  of 
the  face  was  14  inches.  The  circumference  of  the  lips  was 
9^  inches.  The  patient  was  only  thirty-two,  and  the 
disease  appeared  to  have  commenced  eleven  years  before,  in 
a  small  swelling  below  the  right  canine  tooth,  but  the  whole 
of  the  large  growth  had  taken  place  within  four  or  five 
years.  The  fungous  protrusions  were  the  result  of  the 
application  of  quack  remedies. 


352 


MALIGNANT   TUMOURS    OF    THE    LOWER    JAW. 


The  patient  was  in  a  miserable  condition,  being  nearly 
starved,  owing  to  tlie  tumour  forming  a  projecting  mass 
within  the  mouth,  which  completely  concealed  the  tongue, 
and  was  nearly  in  contact  with  the  palate.     I  succeeded 


Fig.  156. 


in  removing  the  tumour  by  sawing  m  front  of  the  left 
angle  and  disarticulating  on  the  right  side,  with  very 
little  loss  of  blood,  but  the  patient  died  exhausted  on 
the  sixth  day.  The  tumour  weighed  41b.  6oz.,  and  is 
now  in  the  Museum  of  the  College  of  Surgeons.  Its 
appearance  (reduced  to  about  one-third)  is  shown  in  Fig. 
156.     A    section    has    been  made  to    show  its  structure, 


EPITHELIOMA    OF    THE    LOWER    JAW,  35  3 

which  is  precisely  that  described  by  Sir  P.  Crampton,  the 
mass  being  made  up  of  fibro-cellular  tissue  of  different 
degrees  of  density,  with  here  and  there  small  nodules  of 
bone,  and  a  few  small  cysts  interspersed  through  its 
structure.  The  tumour  evidently  commenced  in  the  in- 
terior of  the  jaw,  the  outer  plate  being  considerably  ex- 
panded and  destroyed  in  parts,  while  the  inner  remains 
perfect,  and  can  be  seen  in  the  condition  in  which  it  was 
left  at  the  operation.  The  mass  in  growing  has  carried  up 
the  teeth  with  it,  and  they  project  from  it  at  irregular 
intervals,  a  considerable  portion  of  the  growth,  and  probably 
the  most  recently  formed  part,  being  posterior  to  them, 
occupying  as  it  did  the  mouth  and  lying  among  the  muscles 
beneath  the  tongue.  The  fungoid  masses  are  covered  with 
granulations,  but  otherwise  differ  in  no  way  from  the  rest  of 
the  growth. 

Mr.  Eve  has  examined  this  tumour,  and  has  found 
scattered  throughout  it  masses  and  cylinders  of  e])ithe- 
lial  cells,  resembling  the  epithelial  elements  of  the  cystic 
tumours  of  the  lower  jaw  already  described  (p.  198).  They 
were  composed  of  large  irregularly  shaped  or  branched  masses, 
and  of  small  columns  composed  of  round  epithelial  cells, 
with  a  layer  of  peripheral  elongated  cells.  (For  drawing,, 
see  Lecture  by  Mr.  Eve,  British  Medical  Journal,  Jan.  6th, 
1883.) 

In  all  probability  this  tumour  did  not  originate  from  the 
epithelium  of  the  gum,  as  it  presented  no  squamous  character. 
It  is  more  likely  to  have  originated  in  the  paradental  epi- 
thelium already  described  (see  p.  174). 

Squamous  eijitheliorna  is  met  with  more  commonly  in  the 
lower  jaw  than  the  columnar  variety.  It  always  originates 
in  the  epithelium  of  the  gum,  and  may  form  a  typical  epi- 
theliomatous  ulcer  of  the  gums,  which  has  already  been 
described  in  the  chapter  on  "Diseases  of  the  Gums." 

In  other  cases,  however,  it  forms  a  distinct  tumour  of  the 
jaw.  The  following,  under  my  own  care,  is  a  typical  case 
of  the  latter  form  of  the  disease.  A  man,  aged  fifty-six,  first 
noticed  a  swelling  in  his  face  four  months  before  his  admission :, 

z 


354         maligna:\tt  tumours  of  the  lower  jaw. 

he  used  to  liave  toothache,  and  had  lost  all  the  teeth  behind 
the  left  lateral  incisor  in  the  lower  jaw.  When  first  noticed, 
the  tumour  was  about  the  size  of  a  small  walnut,  and  was 
situated  on  the  left  ramus  near  the  angle  of  the  jaw.  It 
was  not  painful  or  tender  to  the  touch,  but  grew  steadily. 
On  admission  to  University  College  Hospital,  there  was  on 
the  left  side  of  the  lower  jaw  a  rounded,  smooth  swelling, 
which  extended  from  the  middle  of  the  vertical  ramus  of  the 
jaw  to  the  level  of  the  hyoid  bone  below,  and  forwards  nearly 
to  the  symphysis.  The  swelling  was  firm  and  inelastic,  and 
the  skin  over  it  was  normal,  except  that  it  was  slightly 
reddened  over  the  anterior  half  of  the  growth.  Inside  the 
mouth  the  growth  projected  as  a  large  red  roundish  mass, 
with  the  surface  flattened  and  sloughy.  It  reached  as  far 
backward  as  the  vertical  ramus,  and  encroached  upon  the 
floor  of  the  mouth.  I  removed  the  tumour,  with  the  portion 
of  the  lower  jaw  implicated,  by  dividing  the  lower  lip  in  the 
median  line  and  carrying  an  incision  beyond  the  angle  of 
the  jaw.  The  jaw  was  sawn  to  the  right  of  the  median 
line,  between  the  incisor  and  the  canine  teeth,  and  the 
tongue  being  secured  with  a  thread,  the  bone  was  disarticu- 
lated on  the  left  side  with  some  little  difficulty,  owing  to  the 
tumour  breaking  away  from  the  upper  part.  Consequently 
the  coronoid  process  was  nipped  off  with  bone-forceps,  and 
an  elevator  was  used  to  lift  the  condyle  out.  There  was 
very  little  bleeding,  and  only  one  or  two  ligatures  were 
applied.  The  wound  was  sprinkled  with  iodoform,  and 
brought  together  with  wire  sutures,  drainage  being  provided 
for. 

The  patient  made  an  uninterruptedly  good  recovery  and 
left  the  hospital  in  thirty  days. 

The  part  removed  consisted  of  the  remains  of  the  left  half 
of  the  bone,  the  part  between  the  vertical  ramus  and  the 
central  incisors  being  almost  entirely  destroyed  by  the 
growth,  only  a  shell  of  bone  remaining  at  each  end.  On 
section  the  growth  was  of  a  dead  white  colour  where  oldest, 
with  a  firm  margin  advancing  into  the  surrounding  tissues. 
It  consisted  of  a  fibrous   stroma,  in  which   were  scattered 


EPITHELIOMA    OF    THE    LOWER    JAW.  ooo 

numerous  leucocytes  and  spindle  cells,  witli  large  masses  of 
squamous  epithelium  cells,  many  of  which  were  collected  into 
bird's-nest  groups.  The  specimen  is  in  University  College 
Museum. 

The  general  characters  of  squamous  epithelioma  of  the 
jaw  are  well  seen  in  the  foregoing  case.  Eapidity  of  growth, 
with  destruction  of  the  bone,  and  fungation  into  the  mouth, 
are  the  leading  characteristics,  and  nothing  but  early  and 
free  removal  offers  any  chance  of  relief.  In  the  above  case 
the  jaw  in  its  upper  part  was  apparently  healthy,  but  I  had 
no  hesitation  in  disarticulating  so  as  to  be  thoroughly  beyond 
the  disease,  and  I  also  went  well  into  healthy  bone  at  the 
point  of  section  so  as  to  avoid,  as  far  as  possible,  all  risk  of 
recurrence. 

The  question  of  the  necessity  for  the  removal  of  large 
portions  of  bone  in  cases  of  cancer  of  the  lower  jaw  may  be 
here  referred  to.  Some  surgeons  maintain  that,  in  a  case  of 
cancer,  it  is  necessary  to  amputate  at  the  joint  above  the 
disease  in  order  to  obtain  immunity.  But,  if  this  doctrine 
is  to  be  carried  out  fully,  the  entu-e  lower  jaw  should  be 
removed  for  disease  of  one  side,  for  though  the  bone  was 
originally  developed  in  two  halves,  there  is  nothing  to  pre- 
vent malignant  disease  spreading  across  the  symphysis,  as 
was  seen  in  a  case  of  epithelioma  under  my  own  care. 

No  definite  rule  can  be  laid  down  concerning  this  point, 
excepting  that  the  incisions  made  for  the  removal  of  the 
growth  should  go  well  beyond  the  disease.  In  very  few 
cases  would  it  be  necessary  to  remove  the  entire  lower 
jaw. 

The  lower  jaw  is  liable  to  be  invaded  by  epithelioma 
spreading  to  it  from  the  tongue,  and  from  the  lip  or  other 
parts  of  the  face,  and  may  be  affected  by  both  sarcoma 
and  carcinoma  developed  in  the  neighbouring  lymphatic 
glands. 

On  more  than  one  occasion  I  have  found  epithelioma  of 
the  anterior  part  of  the  tongue  attached  to  and  infiltrating 
the  central  portion  of  the  lower  jaw,  and  have  been  obliged 
to  cut  out  the  incisive  region  with  good  result  (p.  248). 


356  MALIGNANT    TUMOUES    OF   THE   LOWEE    JAW. 

In  the  cases  of  recurrent  epithelioma  of  the  lip,  when 
the  disease  shows  itself  in  the  sub-mental  glands,  which 
become  adherent  to  and  implicate  the  bone,  it  is  possible  to 
give  relief,  for  a  time  at  least,  by  sawing  out  the  portion  of 
bone  involved,  as  I  did  in  an  old  man  in  May,  1876. 
In  two  instances  I  have  sawn  off  the  chin  only,  without 
breaking  the  line  of   the  alveolus,  or  opening  the  cavity  of 


Fig 


the  mouth.  Fig.  157  shows  the  first  patient  on  whom  I 
performed  the  operation. 

Fig.  158  shows  a  somewhat  unusual  form  of  recurrence 
after  successful  removal  of  epithelioma  of  the  lip,  the  growth 
involving  the  left  side  of  the  lower  jaw  and  implicating  the 
skin  over  it.  I  removed  the  left  half  of  the  lower  jaw  by 
sawing  through  the  ramus,  and  included  the  skin  involved ; 
but  though  the  patient  made  a  good  recovery,  the  disease 
returned  before  many  months,  and  proved  fatal. 

Sarcomatous  growths  in  the  sub-maxillary  lymphatic 
glands  tend,  after  a  time,  to  imphcate  the  lower  jaw,  of  which 
it  may  be  necessary  to  remove  a  portion  with  the  tumour. 


EPITHELIOMA    OF    THE    LOWER    JAW. 


357 


A  specimen  in  the  Museum  of  the  College  of  Surgeons  is 
the  left  half  of  a  jaw-bone,  the  body  of  which  has  been,  to 
a  great  degree,  destroyed  by  the  growth  of  a  firm  substance, 
which  appears  to  have  been  developed  on  the  exterior  of  the 
bone,  and  to  have  gradually  produced  ulceration  and 
necrosis  of  it.  At  the  angle  of  the  jaw,  adjacent  to  the 
growth,  the  bone   is   deeply  and  irregularly  ulcerated,  and 

Fig.  158. 


near  the  symphysis  several  portions  of  it  are  completely 
detached.  The  patient  was  a  man  of  forty-five,  and  the 
disease  began  in  a  hard  enlargement  in  the  situation  of  the 
sub-maxillary  gland.  After  increasing  for  a  year  it  extended 
into  the  mouth,  where  a  fungous  growth  protruded,  and 
subsequently  the  integuments  of  the  cheek  sloughed  and 
rapidly  ulcerated,  and  the  patient  died  exhausted.  After 
death  secondary  growths  were  found  in  the  lungs  and 
liver. 

By  the  kindness  of  Mr.  Wilkes,  of  Salisbury,  I  was  en- 


;58 


MALIGNANT    TUMOUES   OF    THE    LOWER    JAW. 


abled  to  send  to  the  College  of  Surgeons'  Museum  a  tumour 
near  the  angle  of  the  jaw,  for  which  that  gentleman  ampu- 
tated one-half  of  the  bone,  which  was  exhibited  to  the 
Pathological  Society  of  London,  in  May,  1862.  The  patient 
was  a  man  of  fifty,  who  had  a  globular  mass  below  the 
middle  of  the  horizontal  ramus  of  the  jaw,  adherent  to  the 
bone,  but  movable.  The  angle  of  the  jaw  was  roughened 
near  the  growth.  After  removal  of  the  half  of  the  jaw  the 
tumour  was  found  to  be  enclosed  in  a  thick  fibrous  capsule, 

Fig.  159. 


connected  with  the  periosteum.  Microscopically  the  tumour 
was  composed  of  very  small  round  cells,  with  very  little 
stroma.  It  was  probably  a  lympho-sarcoma,  and  may  have 
originated  in  the  sub-maxillary  lymphatic  glands. 

I  have  recently  had  under  my  care  a  man  of  sixty-six, 
who  noticed  some  stiffness  of  the  neck  for  about  six  months 
before  he  discovered  a  tumour  near  the  left  angle  of  the 
jaw.  When  he  came  under  my  care,  three  months  later, 
there  was  on  the  left  side  of  the  face  a  new  growth,  in- 
volving the  angle  and  horizontal  ramus  of  the  jaw,  and 
reaching  to  the  sterno-mastoid  behind  and  the  level  of  the 
thyroid  cartilage  below.     The  skin  was  reddened  and  ad- 


EPITHELIOMA    OF    THE    LOWEK    JAW.  3 5 9 

herent,  and  at  one  point  had  given  way.  There  was  no 
ulceration  of  the  mucous  membrane  of  the  mouth,  and  the 
glands  in  the  neck  were  not  enlarged.  I  isolated  the 
growth  by  a  curved  incision,  including  the  implicated  skin, 
and  then  sawed  through  the  loM'er  jaw  behind  the  second 
bicuspid  tooth,  and  immediately  above  the  angle.  The 
patient  vomited  persistently  after  the  operation,  and  sank 
on  the  seventh  day. 

The  specimen  shows  that  the  lower  jaw  is  surrounded  by 
a  new  growth  which  clings  tightly  to  the  periosteum,  but 
does  not  reach  up  to  the  edentulous  alveolar  border.  The 
hard  bone  of  the  lower  border  of  the  jaw  is  destroyed,  and 
the  growth  penetrates  into  the  cancellous  tissue.  The  sub- 
maxillary gland  lying  on  the  inner  surface  of  the  mass  is 
being  gradually  absorbed,  the  growth  pressing  on  its  inner 
surface.  The  surface  of  the  tumour  (Fig.  159)  is  surrounded 
by  a  distinct  outline,  separating  it  from  the  neighbouring  fat. 
It  appears  to  have  commenced  in  the  lymph-gland  on  the 
parotid,  for  of  this  there  is  no  trace  whatever ;  the  remains 
of  the  sub-maxillary  salivary  gland  appear  perfectly  healthy. 

Microscopically  the  growth  proved  to  be  squamous  epi- 
thelioma, consisting  of  the  ordinary  stroma,  through  which 
were  scattered  ordinary  squamous  epithelial  cells  with 
'  bird's-nest '  fairly  well  marked.  It  is  a  little  difficult  to 
explain  this  occurrence  of  squamous  epithelioma,  since  the 
mouth  was  in  no  way  involved,  and  so  far  as  could  be  made 
out  there  was  no  primary  disease  elsewhere. 


CHAPTEE  XXI. 

DIAGNOSIS    AND    TREATMENT    OF   TUMOURS    OF   THE 
LOWER    JAW. 

Diagnosis. — The  diagnosis  of  tumours  of  the  lower  jaw  is 
easier  than  in  the  case  of  the  upper  jaw.  Slowness  of 
growth,  hardness,  and  isolation  point  to  a  non-malignant 
tumour,  and  this  will  be  confirmed  if  there  is  no  tendency 
to  fungate  within  the  mouth,  and  no  enlargement  of  the 
neighbouring  lymphatic  glands.  Simple  tumours  of  the 
lower  jaw,  if  allowed  to  grow  unchecked,  may  after  a  time 
burst  through  the  skin,  and  thus  give  rise  to  a  fungating 
mass,  which,  however,  is  of  slower  growth  and  more  healthy 
appearance  than  the  malignant  fungus.  Eapidly  growing 
tumours  are  almost  invariably  cancerous,  and  the  only  chance 
for  the  patient  is  their  early  removal,  with  the  portion  of 
bone  implicated. 

The  progTwsis  after  removal  of  tumours  of  the  lower  jaw 
is  more  favourable  than  elsewhere,  since,  owing  to  the 
anatomical  relations,  it  is  easy  to  get  rid  of  the  whole 
disease.  The  question  of  the  return  of  cancer  being  in- 
fluenced by  removal  of  one-half  of  the  bone  is,  as  already 
mentioned,  still  an  open  one. 

The  successful  recoveries  following  removal  of  large 
portions  of  the  lower  jaw  are  very  remarkable,  operations 
on  the  lower  jaw  being  as  a  rule  attended  by  little  constitu- 
tional disturbance.  Mr.  Cusack  removed  large  portions  in 
seven  cases,  with  only  one  fatal  result,  which  was  due  to 
erysipelas  and  oedema  of  the  glottis.  Dupuytren  operated 
in  twenty  cases,  with  only  one  death  resulting  from  the 
operation,  and  that  from  the  same  cause  as  in  Mr.  Cusack's 


OrEEATIONS    ON    THE    LOWER   JAW.  361 

fatal  case.  The  experience  of  modern  surgeons  is  equally 
favourable.  When  the  disease  is  of  ordinary  dimensions, 
and  the  patient  is  in  fair  health,  the  results  are  exceedingly 
satisfactory. 

Operations  on  the  Loioer  Jaw, — Small  tumours,  involving 
the  alveolus,  may  be  removed  with  bone-forceps  without  any 
incision  through  the  skin,  and  even  a  considerable  portion  of 
the  central  part  of  the  lower  jaw  may  be  removed  without 
incising  the  lip,  if  the  mucous  membrane  between  it  and  the 
bone  be  freely  divided  and  the  lip  drawn  well  down.  The 
large  forceps  figured  at  page  243  are  particularly  useful  in 
attackinsj  tumours  situated  in  the  molar  region  without 
external  incision,  and  the  gouge  and  chisel  should  be  freely 
employed  for  the  enucleation  of  benign  tumours  in  the  in- 
terior of  the  lower  jaw. 

The  late  Mr.  Maunder  {Medical  Times  and  Gazette,  July, 
1874)  removed  two  fibrous  tumours  of  the  lower  jaw  of 
considerable  size  without  any  external  incision,  separating 
the  soft  parts  with  a  raspatory,  and  sawing  the  bone  in  front 
of  and  behind  the  tumour.  The  principal  difficulty  in  these 
operations  was  not  so  much  the  separation  of  the  tumour  as 
its  'delivery'  through  the  mouth,  which  was  slightly  split 
in  one  instance.  Fortunately  the  htemorrhage  in  both  cases 
was  slight  and  the  patients  did  well,  but  another  surgeon 
who  adopted  the  proceeding  was  less  fortunate,  and  lost  his 
patient  by  secondary  hsemorrhage,  which,  considering  the 
close  proximity  of  the  facial  artery,  and  the  necessary  division 
of  the  inferior  dental  artery,  is  not  very  surprising.  For 
my  own  part,  I  do  not  think  the  extra  trouble  and  risk 
of  the  proceeding  are  balanced  by  the  absence  of  a  scar, 
which,  in  the  majority  of  cases,  need  not  involve  the  lip, 
and  if  properly  placed  will  be  nearly  invisible  afterwards. 
The  same  may  be  said  of  the  so-called  '  sub-periosteal  re- 
sections '  of  the  lower  jaw.  In  cases  of  necrosis  it  is,  of 
course,  advisable  to  preserve  all  the  periosteum,  and  in 
extracting  a  sequestrum  it  may  be  occasionally  necessary  to 
turn  aside  soft  parts  with  a  raspatory,  but  any  systematic 
stripping  of  periosteum  from  a  jaw  involved  in  a  tumour. 


362  OPERATIONS    ON    THE    LOWER    JAW. 

is  not  only  impossible,  but,  if  undertaken,  will  surely  leave 
shreds  of  periosteum  with,  possibly,  some  portion  of  disease 
attached. 

In  order  to  operate  satisfactorily  within  the  mouth  it  is 
essential  that  the  jaws  should  be  kept  fully  asunder,  and  I 
have  found  nothing  so  convenient  for  the  purpose  as  a  simple 
vulcanite  '  prop,'  similar  to  that  used  by  dentists,  placed  in 
position  on  the  side  opposite  to  the  disease  before  the  adminis- 
tration of  chloroform.  A  string  attached  to  it  obviates  any 
danger  of  its  being  swallowed. 

The  ingenious  gag  invented  by  Dr.  Wingrave  (Fig.  1 60) 
may  also  be  employed  for  the  same  purpose.    It  is  automatic, 

Fig.  160. 


opening  by  means  of  a  spiral  spring,  and  locking  by  reason 
of  the  curved  form  of  the  bar. 

"When  a  large  portion  of  the  body  and  ramus  has  to  be 
removed,  a  curved  incision  may  be  advantageously  carried 
along  the  posterior  margin  of  the  tumour,  so  that  the  scar 
may  be  well  out  of  sight  afterwards.  In  this  the  facial 
artery  will  be  necessarily  divided  at  the  anterior  border  of 
the  masseter  muscle,  and  it  is  advisable  to  secure  both  ends 
immediately  with  ligatures,  or  the  patient  may  lose  a  con- 
siderable quantity  of  blood.  The  tissues  being  then  dissected 
off  the  tumour,  a  careful  examination  of  it  should  be  made, 
to  see  if  it  be  possible  to  extract  the  tumour  by  removing 
the  external  plate  of  bone  with  the  gouge  and  bone-forceps  ; 
and  no  harm  can  come  of  such  an  attempt,  even  if  it  prove 
abortive,  since  no  vessel  of  importance  is  interfered  with. 


OPEKATIONS    ON    THE    LOWER    JAW.  363 

If  necessaiy,  however,  a  small  saw  can  be  applied  in  front 
of  and  behind  the  affected  portion,  which  can  then  be  readily 
isolated  and  removed. 

In  making  these  sections  of  the  lower  jaw  it  is  better  not 
to  complete  one  before  the  other  is  begun,  because  of  the  loss 
of  resistance  consequent  upon  breaking  the  continuity  of  the 
bone ;  but  both  cuts,  being  carried  nearly  through  the  bone 
with  the  saw,  may  be  conveniently  completed  together  with 
the  bone-forceps. 

When  the  central  portion  of  the  lower  jaw  is  removed,  it 
is  well  to  take  precautionary  steps  to  avoid  the  possibility 
of  the  tongue  falling  back  and  suffocating  the  patient.  A 
ligature  should  therefore  be  passed  through  the  tip  of  the 
tongue,  which  will  enable  a  trustworthy  assistant  to  keep 
it  drawn  forward  until  the  operation  is  completed.  The 
ligature  should  then  be  attached  to  one  of  the  hare-lip  pins 
with  which  the  wound  is  closed,  and  may  safely  be  cut  and 
removed  on  the  second  or  third  day.  In  all  cases  in  which 
the  inferior  dental  artery  will  be  divided,  the  operator  should 
be  provided  with  a  line  Paquelin's  cautery  or  a  small  plug  of 
wood,  which  may  be  thrust  into  the  dental  canal  to  stop  all 
bleeding. 

Amputation  of  one  side  of  the  lower  jaw  can  be  conve- 
niently performed  through  an  incision  running  along  the 
posterior  margin  of  the  bone,  from  the  level  of  the  lobule  of 
the  ear  to  the  median  line,  where,  if  the  size  of  the  tumour 
renders  it  necessary,  a  vertical  incision  may  be  carried  through 
the  lip  (Fig  i6i).  The  facial  artery  having  been  secured, 
the  tissues  of  the  cheek  and  the  masseter  are  dissected  up, 
without  injuring  the  flap  and  without  prolonging  the  incision 
upwards,  by  which  the  facial  nerve  would  be  of  necessity 
divided.  A  tooth  having  been  extracted  at  the  point  where 
the  bone  is  to  be  divided,  this  is  effected  with  a  small 
straight-backed  saw,  and  the  bone  having  been  grasped  with 
the  'lion-forceps,'  is  drawn  forcibly  outwards,  whilst  the 
knife  is  run  along  its  inner  side,  care  being  taken  to  keep 
close  to  the  bone,  so  as  not  to  endanger  the  sub-maxillary 
gland   or  lingual   nerve.       The   internal   pterygoid    muscle 


364 


OPERATIONS    ON    THE    LOWER   JAW. 


having  been  carefully  separated  from  the  bone,  forcible 
traction  is  to  be  made  upon  the  jaw,  so  as  to  depress  the 
coronoid  process,  which  by  a  few  touches  of  the  knife  is 
freed  from  the  fibres  of  the  temporal  muscle.  The  joint 
being  now  in  view,  the  knife  is  to  be  applied  to  the  front  of 
it,  when  the  condyle  will  be  at  once  dislocated,  and  the 
knife  can  be  carried  cautiously  behind  it,  so  as  to  isolate  it. 
A  forcible  wrench  of  the  bone  will  now  tear  through  the 

Fig.  i6i. 


few  remaining  fibres  of  the  external  pterygoid  muscle,  and 
the  bone  can  be  removed  (Fig.  162).  At  the  same  time 
care  must  be  taken  not  to  twist  the  jaw  outwards,  so  as  to 
force  the  condyle  and  neck  of  the  bone  against  the  internal 
maxillary  artery,  which  might  thus  be  torn. 

In  order  to  obviate  the  difficulty  which  often  occurs  at 
this  stage  of  the  operation,  Dr.  Gross  recommends  a  flat 
bone-elevator,  to  clear  the  coronoid  process  and  condyle,  and 
thus  avoid  all  danger  to  the  artery.  Having  employed  this 
plan  on  several  occasions  I  can  strongly  recommend  it. 
Mr.  Bryant  has  in  some  cases  dissected  up  the   periosteum 


OPEKATIONS    ON    THE    LOWER    JAW. 


36i 


and  slipped  the  condyle  out  of  it,  but  there  appears  to  be  a 
danger  of  leaving  disease  behind  in  many  cases,  if  this  plan 
were  generally  adopted. 

In  the  case  of  small  tumours,  removal  of  one-half  of  the 
lower  jaw  is  sufficiently  easy,  but,  when  the  tumour  is  large, 
it  may  so  completely  wedge  in  the  upper  part  of  the  bone 

Fig.  162. 


as  to  hinder  the  freeing  of  the  coronoid  process,  and  prevent 
dislocation.  Under  these  circumstances  the  best  plan  is  to 
use  the  bone-forceps  to  cut  off  the  coronoid  process,  or  to 
re-apply  the  saw  and  cut  off  the  tumour  as  high  as  may  be, 
and  subsequently  to  remove  the  remaining  portion  of  jaw, 
if  the  disease  is  malignant,  but  not  otherwise.  Another 
complication  is  when  the  tumour  breaks  away  from  the 
upper  part  of  the  jaw  during  the  operation,  thus  rendering 


366  OPERATIONS    ON    THE    LOWER    JAW. 

it  difficult  to  dislocate  the  condyle,  owing  to  the  want  of 
leverage.  The  '  lion-forceps  '  of  Sir  "William  Fergusson  is 
exceedingly  useful  here,  as  I  have  experienced  in  several 
cases. 

When  one-half  of  the  lower  jaw  has  been  removed,  some 
inconvenience  is  experienced  from  the  remaining  portion 
being  drawn  inwards  by  its  muscles.  To  obviate  this,  Mr. 
Nasmyth,  of  Edinburgh,  originally  contrived  some  metallic 
caps  to  fit  the  teeth  of  the  upper  and  lower  jaws,  and  thus 
keep  the  bone  in  position.  Mr.  Liston  speaks  highly  of 
this  apparatus,  and  a  similar  contrivance  made  by  Mr. 
Cartwright  was  of  great  service  in  the  case  of  the  patient 
from  whom  Sir  W.  Fergusson  removed  one-half  of  the 
lower  jaw. 

I  have  employed  a  double  vulcanite  cap  for  the  teeth  for 
the  purpose,  as  being  more  cleanly,  but  have  found  so  much 
pain  caused  by  the  constant  tension  of  the  muscles  of  the 
unaffected  side  which  are  left  without  opponents,  that  I  have 
abandoned  the  method  altogether,  and  was  content  until 
lately  to  allow  the  remaining  portion  of  jaw  to  be  thrust 
inwards.  Eecently,  however,  Mr.  Stanley  Boyd  introduced 
a  piece  of  knitting-needle  between  the  divided  ends  of  a 
lower  jaw  with  good  effect,  and  I  adopted  the  plan  in  a  case 
in  which  I  removed  a  portion  of  the  jaw  for  non-malignant 
disease,  with  satisfactory  results.  The  needle,  which  was 
slightly  bent,  was  introduced  into  the  dental  canal  so  as  to 
maintain  the  chin  in  the  median  line,  and  the  patient  wore 
it  for  some  weeks,  when  one  end  of  the  needle  protruded 
through  the  skin,  and  it  was  then  withdrawn.  The  result 
as  regards  the  patient's  looks  has,  however,  been  very  satis- 
factory, and  I  should  again  adopt  the  plan  in  a  case  of  non- 
malignant  disease  of  the  side  of  the  jaw ;  but  when  the 
symphysis  is  removed  it  appears  to  be  better  to  allow  the 
halves  of  the  jaw  to  fall  together  and  unite. 

In  the  case  of  very  large  tumours,  necessitating  the  re- 
moval of  the  greater  part  of  the  lower  jaw,  the  direction  of 
the  incision  is  a  matter  of  considerable  importance.  A 
semi-lunar  incision  below  the  mouth  was  employed  by  Sir 


OPERATIONS    ON    THE    LOWER   JAW.  o67 

William  Fergasson  in  cases  of  the  kind  ;  the  great  advantage 
being  the  non-interference  with  the  lip  (which  is  dissected 
up  with  the  integuments  of  the  chin),  and  the  fact  that  the 
scar  is  completely  hidden  afterwards.  On  the  other  hand, 
this  incision  necessitates  the  division  of  both  facial  arteries, 
and  if  disarticulation  on  one  side  is  requisite,  will  not  afford 
good  room  for  the  proceeding  without  danger  to  the  facial 
nerve.  In  a  case  of  very  large  epithelioma  of  the  lower 
jaw,  already  described,  I  preferred  an  incision  through  the 
median  line  of  the  lip,  and  was  able  to  dissect  the  flaps 
back  with  great  ease  and  rapidity,  and  to  avoid  cutting 
either  of  the  facial  arteries.  The  median  line  is,  after  all, 
the  best  position  for  a  cicatrix,  and  I  regard  the  division  of 
the  lower  lip,  which  always  readily  unites  again,  as  a  very 
unimportant  matter. 

Whatever  the  operation  which  has  been  performed,  care 
should  be  taken  to  secure  all  bleeding  vessels,  and  when 
there  are  bleeding  points  deep  in  the  wound  which  cannot 
thus  be  treated,  the  actual  cautery  should  be  applied  to 
them.  The  dental  artery,  necessarily  divided  in  sawing  the 
jaw,  is  sometimes  troublesome  if  its  mouth  is  not  touched 
with  the  cautery,  or  the  dental  canal  plugged  with  a  small 
piece  of  wood.  The  incision  in  the  skin  should  be  carefully 
adjusted  with  wire  or  silk  sutures,  and  the  lip  brought 
together  with  hare-lip  pins  and  a  twisted  suture,  fine  silk 
sutures  being  put  in  the  mucous  membrane  lining  the  back 
of  the  lip,  so  as  to  prevent  the  access  of  saliva.  Care  must 
be  taken  to  provide  for  the  drainage  of  the  wound  by  leav- 
ing an  opening  at  the  most  dependent  part,  into  which  a 
drainage  tube  may  be  put,  and  if  necessary  a  light  bandage 
may  be  applied  to  support  the  parts.  At  the  time  of  the 
operation  the  wound  may  be  thoroughly  sponged  out  with  a 
solution  of  chloride  of  zinc  (gr.  40  ad  ^j)?  or  better,  the 
whole  of  the  wound  may  be  thoroughly  sprinkled  with 
iodoform,  which  has  a  most  marked  antiseptic  effect. 

The  after-treatment  consists  in  supporting  the  patient's 
strength  by  administering  fluid  nourishment  with  a  feeder 
or  tube   and   bottle,  and  careful  washing  out  of  the  mouth 


368  OPEKATIONS    ON    THE    LOWER    JAW. 

with  detergent  lotions,  so  as  to  keep  it  clean  and  healthy 
during  the  process  of  healing  ;  and  when  the  effects  of  the 
iodoform  have  worn  off,  nothing  is  more  effective  as  an 
antiseptic  than  the  glycerinum  acidi  carbolici  freely  applied 
with  a  camel^s-hair  brush. 

Operations  on  the  lower  jaw  are  quite  of  modern  date. 
Anthony  White,  of  the  Westminster  Hospital,  appears  to 
have  been  the  first  surgeon  who  removed  a  portion  of  the 
lower  jaw  ( 1 804).  He  was  followed  by  Dupuytren  (i  8 1 2), 
Mott  and  Grafe  (1821),  and  Sir  P.  Crampton  in  1824. 
Cusack's  celebrated  cases  of  disarticulation  occurred  imme- 
diately afterwards,  and  the  operation  became  an  established 
one.  The  names  of  Listen,  Syme,  and  Fergusson  have 
been  prominent  in  connection  with  the  operation  in  this 
country,  whilst  abroad  Lisfranc,  Lallemand,  Maisonneuve, 
Gensoul,  and  other  eminent  men,  have  given  it  their 
support. 

It  has  been  already  noticed  how  little  deformity  often 
results  from  the  removal  of  portions  of  the  lower  jaw.  Al- 
though the  bone  is  never  reproduced,  a  development  of  firm 
fibrous  tissue  takes  its  place,  which  affords  support  to  arti- 
ficial teeth,  and  to  which  the  muscles  gain  a  firm  attach- 
ment, In  February,  1855,  Mr.  Spence,  of  Edinburgh, 
brought  before  the  Medico- Chirurgical  Society  of  Edinburgh 
a  preparation  illustrating  this  point  in  a  marked  manner. 
Eighteen  years  before  the  patient's  death,  Sir  William 
Fergusson  had  removed  the  greater  part  of  the  right  side  of 
the  lower  jaw.  Five  years  later  Mr.  Spence  had  removed 
the  left  side  of  the  jaw  from  within  half  an  inch  of  the 
symphysis  to  the  articulation,  and  the  condition  found  at 
death,  thirteen  years  after,  is  thus  described  (Edinlurgh 
Medical  Journal,  April,  1855):  "A  dense  fibrous  texture 
connected  the  small  portion  of  the  ascending  ramus  of  the 
right  side  with  the  remaining  portion  near  the  symphysis, 
whilst  on  the  left  side  a  similar  texture  occupied  the  place 
of  the  disarticulated  bone,  on  both  sides  affording  firm 
attachments  to  the  masseters  and  other  muscles,  so  that  the 
patient  during  life  had  considerable  use  of  the  mouth." 


OPERATIONS    ON    THE    LOWER  JAW.  861) 

The  tendency  of  the  muscles  to  force  the  remaining  por- 
tion of  the  jaw  out  of  place  has  been  already  referred  to. 
In  cases  in  which  the  central  portion  of  the  jaw  has 
been  removed,  the  force  of  the  muscles  on  both  sides  being 
equally  exerted,  the  rami  of  the  jaw  become  closely  approxi- 
mated, and  are  united  by  very  firm  fibrous  tissue,  which 
eventually  developes  into  bone,  as  in  a  specimen  in  Univer- 
sity College  Museum.  This,  of  course,  gives  a  peculiar 
narrowness  to  the  lower  part  of  the  face,  which  is  fortunately 
concealed  in  men  by  wearing  a  beard. 

The  supplying  of  artificial  teeth  to  a  patient  who  has 
undergone  removal  of  a  portion  of  the  lower  jaw  will  tax 
the  ingenuity  of  the  dentist  considerably,  for  when  the 
muscles  have  forced  the  remaining  portion  out  of  position, 
it  becomes  necessary  to  employ  means  to  bring  the  teeth 
into  their  normal  relation  so  as  to  obtain  a  proper  '  bite.' 
The  vulcanite  rubber  forms  a  most  useful  base  for  the  arti- 
ficial teeth,  and  if  firmly  attached  to  the  remaining  portion 
of  jaw  it  moves  very  satisfactorily  with  it,  lying  in  the  hollow 
of  the  cheek  and  resting  upon  the  dense  fibrous  tissue  of 
the  cicatrix. 


2  A 


CHAPTER    XXII. 

PARASITIC    DISEASES    OF    THE   JAWS. 

Actinomycosis. 

Although  actinomycosis  may  be  found  in  almost  any  part 
of  the  body,  yet,  in  the  majority  of  cases,  its  primary  seat 
is  in  the  jaws,  the  lower  jaw  more  frequently  than  the 
upper.    It  is  much  more  common  in  cattle  than  in  man.    It 
has  been  settled  beyond  doubt,  that  the  active  agent  in  pro- 
ducing the  disease  is  a  fungus  termed  actinomyces  or,  from 
its  appearance  under  the  microscope,  the  '  ray-fungus.'    The 
fungus  is  taken  in  through  the  mouth,  and  may  lodge  in 
almost  any  part  of  the  alimentary  or  respiratory  tracts.     It 
has  been  already  mentioned  that  the  jaws  are  the  structures 
most  frequently  affected,  and  the  explanation  of  this  fact  is 
probably  to  be   found  in  the  intimate  relation  that  exists 
between  the  teeth  and  the  jaws.    Any  breach  in  the  integrity 
of  the  teeth,  such  as  is  brought  about  by  decay,  serves  as  a 
gate  through  which  the  fungus  can  enter  and  penetrate  into 
the  interior.     We  find  that  the  clinical  history  of  the  case 
is  in  accordance  with  this  view.    Thus,  the  earliest  symptom 
is  very  frequently  tenderness,  and  sometimes  severe  pain, 
localised  in  one  or  more  of  the  teeth ;  on  examination  the 
teeth  are  found  to  be  carious,  and  the  pain  is  generally 
attributed  to  ordinary  septic  inflammation  caused  by  the 
focus    of   decay.     Within   a   few  weeks  a  swelling  forms. 
When  the  lower  jaw  is  affected  the  swelling  is  situated  at 
the  angle  of  the  jaw ;  when  the  upper  jaw  is  affected  a 
swelling  is  noticed  at  some  part  of  the  cheek.     The  tumour 
is  firmly  fixed  to  the  jaw,  and  may  be  either  soft  or  hard. 


ACTINOMYCOSIS    OF   THE    JAWS. 


371 


As  the  tumour  increases  in  size  the  skin  over  it  becomes 
slightly  inflamed,  and  fluctuation  can  be  readily  detected. 
If  the  swelling  is  not  opened  by  the  surgeon  it  will  finally 
burst.  In  either  case  a  turbid  serous  liquid  escapes,  con- 
taining in  suspension  small  yellow  grains,  which  have  a  very 
characteristic  appearance  and  consist  of  masses  of  the  fungus. 
Around  this  swelling  the  tissues  become  affected  in  diffused 
areas,  which  break  down  in  places  and  form  numerous 
fistulre,  communicating  one  with  the  other  and  opening  on 

Fig,  163. 


the  surface  by  several  crateriform  apertures.  This  condition 
is  well  shown  in  Fig.  163  (Albert).  On  passing  a  probe 
into  the  sinuses  bare  bone  can  be  readily  felt.  A  slight 
amount  of  pus  trickles  away  from  the  openings  of  the 
fistulee.  This  diffuse  infiltration  of  the  skin  and  subcu- 
taneous tissues  may  spread  widely,  passing  downwards  along 
the  neck  and  upwards  to  the  temporal  region.  Sometimes 
the  sub-maxillary  lymphatic  glands  become  inflamed  and  may 
suppurate.  The  spreading  inflammation  may  also  cause  that 
condition  known  as  'closure  of  the  jaw'  (p.  389).  As 
a  rule  the  temperature  is  not  raised,  but  sometimes  there  is 
distinct  fever  if  exit  is  not  given  to  the  purulent  collections. 
The  constant  discharge  of  pus  leads  to  progressive  emacia- 


372  PARASITIC    DISEASES    OF    THE    JAWS. 

tion  and  finally  to  lardaceous  disease.  In  some  eases  septic 
poisoning  accelerates  the  course  of  the  disease.  In  other 
cases  numerous  secondary  foci  develop,  especially  in  the 
lungs.  As  a  rule,  the  course  of  the  disease  is  chronic,  lasting 
one  or  two  years ;  occasionally,  however,  the  disease  takes  a 
very  rapid  course  and  may  terminate  fatally  within  three 
months. 

Prognosis. — Unless  the  disease  be  eradicated  at  an  early 
period  the  prognosis  is  very  grave.  The  progressive  emaci- 
ation and  cachexia  render  the  patient  very  liable  to  fatal 
intercurrent  affections.  Secondary  foci  of  the  disease  may 
appear  in  important  organs,  especially  in  the  lungs,  and  lead 
to  a  fatal  termination.  The  prognosis  appears  to  be  more 
serious  when  the  upper  jaw  is  affected  than  when  the  lower 
jaw  is  attacked. 

In  rare  cases  the  disease  has  been  cured  by  incision  and 
drainage  of  the  tumour.  The  success  of  more  radical 
treatment  has  been  encouraging.  Several  cases  have  been 
recorded  where,  after  thorough  removal  of  the  diseased 
structures,  a  cure  has  taken  place.  If,  however,  secondary 
visceral  foci  have  formed,  the  prognosis  is  probably 
hopeless. 

Diagnosis. — In  many  cases  this  is  most  difficult.  If  the 
characteristic  yellow  bodies  can  be  found,  any  doubt  is  at 
once  cleared  up.  In  some  cases,  however,  they  may  not  be 
found,  even  after  a  prolonged  search.  We  must  then  take  into 
consideration  other  factors.  Thus,  the  occupation  should  be 
ascertained ;  any  work  necessitating  contact  with  cattle  may 
lead  to  infection.  The  chronicity  of  the  disease,  the  spread- 
ing, inflammatory  character,  and  the  formation  of  numerous 
inter-communicating  fistulas,  should  be  borne  in  mind. 

Treatment. — It  is  obvious  that  complete  removal  of  the 
fungus  should  be  aimed  at.  In  very  early  cases  this  might 
be  attained  by  opening  the  swelling  and  thoroughly  scraping 
the  walls  with  a  sharp  spoon.  In  more  advanced  cases,  free 
removal  of  the  skin  and  deeper  structures  with  the  knife, 
combined  with  scraping,  is  necessary.     In  some  cases  the 


MYCOSIS    ASPERGILLINA.  373 

disease  is  too  extensive  to  be  treated  in  this  way.  The 
injection  of  germicides,  especially  perchloride  of  mercury, 
has  been  recommended  in  these  cases.  Owing  to  the  diffuse 
character  of  the  secondary  lesions  in  the  viscera,  operative 
treatment  is  out  of  the  question. 

Mycosis  Asjycrgillina. 

Zarniko  (Deutsche  med.  Woch.,  1891)  records  a  case  of 
mycosis  asperyillina  of  the  antrum  of  Highmore.  The 
following  account  is  taken  from  the  Sivpplement  to  the  British 
Medical  Jounicd,  1891  : 

The  patient,  a  woman,  aged  fifty,  complained  of  nasal 
obstruction,  with  an  offensive  and  copious  nasal  secretion, 
frontal  headache,  and  an  occasional  sense  of  fulness  in  the 
left  ear.  Ehinoscopy  showed  that  both  middle  turbinated 
bones  were  occupied  by  irregular  tumours  attached  by 
a  broad  base,  and  almost  filling  the  middle  meatus  of  the 
nose.  On  the  left  side,  moreover,  was  some  creamy  highly 
offensive  pus,  occupying  the  middle  meatus  and  covering  the 
upper  surface  of  the  lower  turbinated  bone.  This  pus  could 
be  made  to  ooze  freely  if  the  tumour  was  pushed  towards 
the  septum  with  a  probe.  The  soft  palate  was  shortened  by 
cicatrisation  and  drawn  up,  especially  on  the  right  side, 
radiating  cicatrices  being  also  visible  on  the  hard  palate  and 
pharynx.  Zarniko  removed  the  tumours  by  means  of 
a  snare,  and,  as  soon  as  the  wounds  had  healed,  passed  a 
curved  tube  into  the  left  antrum  of  Highmore,  and  syringed 
it  out,  removing  in  this  way  a  number  of  dark  brown,  more 
or  less  friable,  lumps  as  large  as  peas.  On  microscopic 
examination  these  lumps  were  found  to  consist  of  a  fungus, 
presenting  all  the  characters  of  aspergillus  fumigatus 
(Fresenius).  The  antrum  was  regularly  washed  out  with 
boracic  and  corrosive  sublimate  lotions,  rapid  improvement 
taking  place.  The  lumps  disappeared,  together  with  the 
offensive  smell ;  the  discharge  of  pus  also  greatly  diminished. 
Zarniko  considers  this  disease  to  belong  to  the  same  category 


374  PARASITIC    DISEASES    OF    THE    JAWS. 

as  otomycosis.  The  mucous  membrane  of  the  antrum,  when 
healthy,  is  probably  unsuited  to  be  a  soil  for  the  aspergillus, 
but,  in  this  case,  it  may  possibly  have  become  suited  as  a 
result  of  serous  catarrh,  the  growth  of  the  fungus  provok- 
ing and  maintaining  the  inflammatory  condition  observed. 
Zarniko  recommends  that  the  disease  should  be  attacked 
through  the  middle  meatus.  This  method  is  simpler  than 
any  other. 


CHAPTER  XXIII. 

DISEASES    OF   THE    TEMPOEO-MAXILLARY    ARTICULATION. 

The  temporo-maxillary  articulation  is,  like  other  joints,  the 
subject  of  inflammation  due  to  constitutional  and  local 
causes,  to  which  latter  its  exposed  position  would  seem  to 
render  it  particularly  liable.  Yet  it  is  remarkable  that 
acute  disease  of  the  temporo-maxillary  joint  is  hardly  re- 
corded, and  I  think  the  explanation  is  to  be  found  in  the 
fact  that  it  is  often  confounded  with  acute  affections  of  the 
ear,  and  that  mischief  beginning  in  the  articulation  may 
induce  purulent  discharge  from  the  meatus  in  children. 

That  destructive  disease  of  this  articulation  is  not  very 
infrequent,  is  evident  from  the  number  of  museum  speci- 
mens extant  of  complete  ankylosis,  and  of  the  numerous 
cases  of  fibrous  ankylosis  which  have  been  met  with  in 
practice. 

The  diseases  of  this  joint  may  conveniently  be  divided 
into  acute  arthritis,  chronic  arthritis,  and  tubercular 
disease. 

Acute  Arthritis.  —  The  cases  of  acute  arthritis  are 
numerous,  and  it  would  be  inconvenient  to  classify  them 
according  to  their  causes.  They  fall,  however,  very 
naturally  into  two  groups,  those  that  do  not  suppurate  and 
those  that  do. 

The  three  chief  causes  of  nonsuppurative  arthritis  are 
rheumatism,  injury  and  gonorrhoea.  There  is  swelling  and 
pain  in  the  region  of  the  joint,  and  sometimes  the  pain  may 
spread  to  the  temple  or  ear.  The  pain  causes  spasm  of 
the  muscles,  and  hence  difficulty  or  impossibility  in  opening 
the  mouth.     The  acute  stase  lasts  from  one  to  two  or  three 


376        DISEASES  OF  THE  TEMPOEO-MAXILLAEY  AETICULATION. 

weeks,  and  may  sometimes  terminate  in  partial  or  complete 
ankylosis. 

The  causes  of  suppurative  arthritis  are  various.  The 
inflammation  may  commence  in  the  joint,  or  may  spread 
from  some  neighbouring  structure.  A  severe  injury  may 
lead  to  suppuration,  but  more  commonly  it  occurs  during 
the  course  of  some  specific  disease,  such  as  scarlet  fever, 
measles,  &c.  Mr.  Spanton,  of  Hanley  (Lancet,  April  i6th, 
1881),  reported  two  cases  following  scarlet  fever.  They 
came  under  his  care  for  the  resulting  ankylosis,  which  he 
successfully  treated  by  dividing  the  fibrous  bands  with  a 
tenotome  passed  into  the  articulation.  A  considerable 
number  of  the  cases  are  secondary  to  suppuration  in  the 
neighbourhood.  Thus,  in  Guy's  Hospital  Museum  is  the 
skull  of  a  negro  who  had  disease  of  the  cervical  vertebrae, 
and  complete  osseous  ankylosis  of  the  temporo-maxillary 
articulation,  coming  on  after  a  wound  in  the  neck  from  a 
fork.  The  history  of  the  man,  with  a  drawing  of  the  skull, 
will  be  found  in  Mr.  Hilton's  "  Lectures  on  Eest  and 
Pain." 

In  some  cases,  no  doubt,  the  inflammation  is  secondary  to 
suppurative  otitis  media.  This  occurred  in  a  gentleman, 
aged  twenty-five,  who  was  sent  to  me  by  my  friend.  Dr. 
Bate.  I  saw  him  first  in  February,  1866,  when  be  told  me 
that  he  had  the  measles  badly  when  nine  years  old,  and 
this  was  followed  by  discharge  from  the  left  ear,  which 
became  deaf.  The  discharge  had  ceased  for  two  years,  when 
in  September,  1864,  he  caught  a  severe  cold,  and  it  recom- 
menced, and  at  the  same  time  the  left  temporo-maxillary 
articulation  became  swollen  and  stiff,  so  that  he  was  obliged 
to  live  by  suction  for  some  time.  The  discliarge  from  the 
ear  was  very  profuse,  as  much  as  half  a  pint  at  a  time,  and 
matter  burrowed  under  the  tissues  of  the  face  as  high  as  the 
orbit,  where  a  small  opening  formed,  and  down  the  neck, 
discharging  into  the  throat  for  three  days.  Finding  the 
left  lower  wisdom  tooth  cut  awry  and  very  far  back,  I 
thought  that  this  might  possibly  be  connected  with  the 
disease,  and  therefore  had  it  extracted,  with  some  difficulty, 


CHRONIC    TEMPOKO-MAXILLARY    ARTIIKITLS.  o77 

Ly  Mr.  Muiamer}-.  In  the  following  July  I  found  that  he 
had  derived  no  benefit  from  the  extraction,  and  the  jaws 
were  as  firmly  closed  as  before.  The  space  between  the 
incisors  was  k  inch,  and  rather  more  between  the  bicuspids 
on  the  left  side.  The  mouth  did  not  open  so  widely  as  it 
had  done  eighteen  months  before,  but  he  had  perceived  no 
diflerance  during  the  preceding  six  months.  There  was  no 
external  deformity,  but  he  said  he  heard  a  grating  sound  on 
moving  the  jaw  which  was  not  audible  externally. 

My  colleague,  Mr.  Arthur  Barker,  in  his  valuable  article 
on  Diseases  of  the  Joints  ("  System  of  Surgery,"  vol.  ii),  men- 
tions that  in  cases  of  suppuration  of  the  middle  ear,  the 
temporo-maxillary  articulation  may  become  involved  through 
the  floor  of  the  meatus,  in  which  a  hiatus  often  exists  in 
children.  He  quotes  in  proof  of  this  a  case  which  I  had 
long  under  my  care,  a  child,  from  whose  meatus  the  condyle 
of  the  jaw  was  extracted ;  but  I  should  rather  regard  it  as  a 
case  in  which,  from  disease  of  the  temporo-maxillary  joint, 
perforation  had  ensued,  and  the  condyle  had  found  its  way 
into  the  meatus. 

Chronic  Arthritis. — The  researches  of  the  late  Dr.  Eobert 
Adams  and  Dr.  E.  W.  Smith,  of  Dublin,  have  shown  that 
rheumatoid  arthritis  occasionally  affects  the  temporo-maxil- 
lary articulation,  and  the  former  author  has,  in  his  '  Atlas, 
figured  the  remarkable  hypertrophy  of  the  neck  of  the 
condyle  of  the  jaw,  occurring  in  the  case  of  a  woman,  aged 
thirty,  to  which  I  shall  have  occasion  to  refer  more  par- 
ticularly later  on. 

Cruveilhier,  who  first  described  an  example  of  rheumatoid 
arthritis  of  the  temporo-maxillary  articulation  (Anatomie 
Patliologiiiiic,  11  v.  ix),  says :  "  I  have  never  seen  the 
disease  I  call  wearing  away  of  the  articular  cartilages  better 
marked  than  it  was  in  this  case.  The  condyle  of  the  lower 
jaw  did  not  exist ;  it  might  be  supposed  to  have  been  sawn 
off"  horizontally  at  the  line  of  junction  of  the  head  with  the 
neck,  and  that  which  remained  of  the  neck  had  been  flat- 
tened. The  articular  part  of  the  glenoid  cavity  was  repre- 
sented merely  by  a  plane  surface  ;  no  trace  of  inter- articular 


178 


DISEASES  OF  THE  TEMPOEO-MAXILLARY  AKTICULATION. 


cartilage  or  cartilage  of  incrustation  existed.     Both  surfaces 
of  the  altered  articulation  were  remarkably  red." 

I  have  never  had  the  opportunity  of  examining  a  recent 
example  of  this  disease,  but  as  far  as  can  be  judged  from 


Fig.  164. 


Fig.  165. 


museum  specimens,  the  articular  surface  of  the  condyles  is 
flattened  and  somewhat  altered  in  direction  in  the  less 
marked  instances  (Fig.  164),  and  absorption  of  the  neck, 
with  complete  wearing  away  of  the  articular  surfaces  (Fig. 
165),  occurs  in  the  older  and  more  advanced  cases.    I  agree 


Fig.  166. 


with  Dr.  Adams,  that  eburnation  of  the  articular  surfaces, 
or  the  occurrence  of  porcellanous  deposit  in  the  temporo- 
maxillary  articulation,  is  very  rare.  The  description  quoted 
from  the  St.  Bartholomew's  Catalogue  by  Dr.  Adams  refers 
to  preparation  No.  551  in  that  museum  (Fig.  166),  and  is 
as  follows : 

"  There  has  been  disease  in  one  of  the  articulations  of  the 


HYPEKTROPIIY    (JF    THE   NECK    AND    CONDYLE. 


379 


jaw,  producing  absorption  of  the  articular  cartilage,  with  a 
deposit  of  bone  around  the  circumference  of  the  glenoid 
cavity.  The  corresponding  condyle  is  in  part  removed  by 
absorption  ;  its  surface  is  rough,  except  at  one  point,  where 
it  is  highly  polished,  and  has  an  ivory-like  texture." 

Enlargement  of  the  glenoid  cavity  is  common  in  these 
cases,  and  is  well  seen  in  Fig.  167,  taken  from  the  same 
specimen  in  St.  Bartholomew's  Hospital.  Absorption  of 
bone  must  of  course  occur  in  these  cases,  but  it  is  worthy  of 
remark  that,  as  pointed  out  by  Dr.  Adams,  the  bone  forming 

Fjg.  167. 


the  fundus  of  the  cavity  is  not  thinned,  but,  if  anything, 
is  thicker  than  in  the  normal  state.  The  entire  disappear- 
ance of  the  inter-articular  fibro-cartilage  is,  apparently,  an 
early  event  in  chronic  disease  of  the  temporo-maxillary 
articulation.  It  had  entirely  disappeared  in  all  the  few 
recorded  post-mortem  examinations,  and  was  absent  in  a 
case  of  hypertrophy  of  the  condyle  in  the  living  subject 
which  I  successfully  operated  on. 

Hypertroi^hy  of  the  Nech  and  Condyle  was  observed  by 
Dr.  Adams  in  the  case  of  rheumatoid  arthritis  of  the 
temporo-maxillary  joint  already  referred  to,  and  is  beauti- 
fully shown  in  Plate  i  of  his  admirable  '  Atlas.'  Though 
occurring  in  a  woman  of  only  thirty,  there  can,  I  think,  be 


380 


DISEASES  OF  THE  TEMPORO-MAXILLARY  ARTICULATION. 


no  doubt,  from  the  description  and  drawings  of  her  hand 
and  feet,  that  the  patient  was  the  subject  of  rheumatoid 
arthritis.  It  is  by  no  means  certain,  however,  that  the 
hypertrophy  of  the  neck  and  condyle  must  be  considered  to 
be  the  results  of  that  disease,  for,  as  I  shall  show,  this 
same  rare  deformity  has  been  found  in  patients  otherwise 
healthy. 

Fig.     1 68    shows   a   lower  jaw   so   like 


that  figured  in 


Fig.  i( 


Adams'  '  Atlas '  in  every  respect,  that  the  preparations 
are  evidently  identical  in  their  nature.  It  was  presented 
to  the  College  of  Surgeons'  Museum  by  Mr.  Jeremiah 
McCarthy,  and  is  thus  described  by  Mr.  Eve  : 

"  A  lower  jaw  with  a  mass  of  bone,  having  somewhat  the 
form  of  an  inverted  pyramid,  attached  to  the  thickened 
neck  of  the  right  condyloid  process.  The  upper  surface  of 
the  mass,  corresponding  to  the  base  of  the  pyramid,  is  flat 
and  smooth  as  if  it  had  been  covered  with  fibro-cartilage 
(Fig.   1 69).      Upon  its  inner  side  is  a  deep  indentation,  from 


HYPEIITROPIIY    OF    THE    NECK    AND    CONDYLE. 


381. 


which  a  fissure  extends  outwards  and  downwards  nearly  to 
the  external  surface  of  the  bone.  The  indentation  and  the 
fissure  constitute  the  upper  boundary  of  a  portion  of  bone, 
which,  from  its  form  and  position,  might  be  taken  for  an 
enlarged  condyle.  The  right  half  of  the  jaw  is  larger  in 
all  its  dimensions  than  the  left  half,  the  breadth  of  the 
horizontal  ramus  in  front  of  the  angle  being  double  that  on 
the  left  side,  which,  from  the    slenderness   of  the  coronoid 


and  condyloid  processes,  appears  atrophied.  From  a 
middle-aged  man,  who  died  with  apoplexy.  There  was  a 
remarkable  deformity  of  the  face  from  the  deviation  of  the 
symphysis  from  the  middle  line ;  and  the  projection  of  the 
enlarged  condyle  was  considerable.  The  base  of  the  skull 
was  not  examined,  and  nothing  was  found  in  the  post- 
mortem examination  except  atheroma  of  the  vessels. 
Nothing  unusual  had  been  noticed  about  his  mouth  in 
childhood,  nor  could  any  account  of  an  injury  be  obtained." 
(See  Pathological  Society's  Transactions,  vol.  xxxiv,  1883.) 

In  the  same  volume  of  the  Pathological  Society^ 
Transactions  will  be  found  the  record  of  a  remarkable 
specimen  of  hypertrophy  of  the   neck  and  condyle   of  the 


382 


DISEASES  OF  THE  TEMPOEO-MAXILLAEY  AETICULATION. 


jaw,  removed  by  myself  from  a  woman,  aged  thirty-six, 
whose  face  had  for  ten  years  become  gradually  more 
deformed,  by  the  increasing  displacement  of  the  chin  to  the 
right  side  and  the  projection  outwards  of  the  left  condyloid 
process.  The  movements  of  the  jaw  were  restricted,  and 
the  length  of  the  left  ascending  ramus  was  three  inches,  of 
the  right  one  inch  and  a  half.  She  had  an  attack  of 
hemiplegia,  implicating  the  left  side  of  the  face,  when   she 


Fig.  170. 


was  twenty-five  years  of  age,  and  from  this  affection  her 
limbs  had  recovered  perfectly  and  her  face  partially. 

The  appearance  of  the  patient  (who  was  sent  to  me 
by  Dr.  Williams,  of  Sherborne)  is  seen  in  Fig.  170, 
and  the  piece  of  bone  removed  is  accurately  drawn 
in  Fig.  171,  the  hypertrophied  condyle  measuring  one 
inch  and  three-quarters  from  before  backwards,  and  one 
inch  across,  and  being  covered  with  fibro-cartilage.  A 
section  of  the  preparation  shows  it  to  be  composed  of 
cancellous  bone  with  large  rounded  sj)aces,  and  its  walls 
are    formed    of    a    thin    layer    of    compact    bone.       The 


HYPERTl;ol'l[V    OF    THE    NECK    AND    CONDYLE.  383 

fissure  observed  in  Mr,  McCarthy's  does  not  exist  in  this 
specimen.  If  the  condyle  thus  shown  is  compared  with 
Fig.  169,  which  represents  the  condyle  of  Mr.  McCarthy's 
case,  of  the  natural  size,  there  can  be  little  doubt  that  my 
preparation,  Mr.  McCarthy's,  and  Dr.  Adams's  all  belong  to 
the  same  category ;  and  yet  in  Mr.  McCarthy's  probably, 
and  certainly  in  my  own  case,  this  was  the  only  joint 
affected.     It    must    be     concluded    then,    I     think,     that 

Fig.  171. 


hypertrophy  of.  the  neck  and  condyle  may  occur  in 
otherwise  healthy  patients,  and  I  believe  that  I  saw,  in 
consultation  with  Mr.  Nathaniel  Stevenson,  the  early  stage 
of  this  curious  condition  in  a  young  healthy  lady  of  about 
twenty,  in  whom  the  lower  teeth  had  gradually  become 
displaced  from  no  known  cause,  so  as  to  disarrange  the 
normal  bite.  I  here  detected,  what  was  then  new  to  me, 
some  hypertrophy  of  the  neck  of  the  jaw  on  one  side,  and 
recommended  blistering  and  a  course  of  iodide  of  potassium 
without  any  marked  benefit,  except  that  the  deformity  has 
not  increased.  In  the  patient,  whose  portrait  is  given  in 
Fig.  170,  the  deformity  was  so  great  as  to  warrant  surgical 


384        DISEASES  OF  THE  TEMPOKO-jMAXILLAEY  ARTICULATIOX. 

interference,  and  the  result  has  been  very  satisfactory,  the 
face  being  brought  straight,  and  the  patient  having  free 
movement  of  the  jaw. 

In  old  age,  after  the  teeth  have  fallen  out,  certain 
changes  take  place  in  the  joint  resembling  those  produced 
by  rheumatoid  arthritis.  "  These  changes  are  frequently 
very  marked.  The  fibro-cartilage  is  very  often  completely 
removed,  the  only  relic  of  it  to  be  found  being  a  fimbriated 
margin  attached  to  the  inner  aspect  of  the  loose  capsule. 
In  other  cases  the  cartilage  is  rendered  thin  throughout  its 
extent,  and  in  others,  again,  it  is  perforated  internally  and 
posteriorly.  The  appearance  presented  by  the  articular 
surface  of  the  head  of  the  jaw,  varies  considerably.  In 
some  cases  the  head,  while  not  diminished  in  breadth,  loses 
its  convexity,  and  is  instead  flattened  on  its  upper  surface, 
the  flat  facet  being  quadrilateral  in  form.  It  may  present 
a  partial  covering  of  cartilage,  but  in  very  many  cases  the 
bone  presents  instead  a  porous  granular  aspect.  In  such 
cases  the  eminentia  is  usually  quite  removed,  the  original 
elevation  being  replaced  by  a  flat  surface,  which  is 
continuous  with  that  forming  the  back  part  of  the  glenoid 
cavity.  This  surface  is  usually  completely  deprived  of  its 
articular  cartilage.  Sometimes  the  head  of  the  jaw  is  much 
constricted  transversely,  and  presents  a  slight  rounded 
convexity,  which  articulates  with  the  inner  part  only  of  the 
glenoid  cavity,  having  cut  for  itself  a  longitudinal  channel 
through  the  inner  portion  of  the  eminentia  articularis,  the 
outer  portion  of  this  convex  surface  of  bone  presenting  but 
slight  changes." 

This  description  is  copied  from  Mr,  Arbuthnot  Lane,  who 
has  published  some  original  views  on  the  mechanical  causa- 
tion and  pathology  of  rheumatoid  arthritis.  (Pathological 
Society'' s  Transactions,  1886). 

These  changes,  in  Mr.  Lane's  opinion, "  are  due  to  the  loss 
of  teeth,  and  to  the  consequent  modification  in  the  normal 
movements  of  the  temporo-maxillary  articulation,  and  the 
general  atrophy  of  the  muscles  of  mastication,  especially  of 
those  that  serve  to  approximate  the  jaws,  namely,  the  masseter 


TUBEllCULAR   ARTICULAR    DISEASE.  08 5 

and  internal  pterygoid.  It  is  owing  to  the  action  of  these 
two  muscles  that  the  form  of  the  angle  of  the  jaw  varies  at 
different  periods  of  life.  As  these  muscles  are  used  witli 
great  vigour  during  young  adult  life,  the  surfaces  of  bone 
into  which  they  are  inserted  become  strong  and  dense,  and 
marked  by  vertical  ridges  indicating  the  attachment  of  the 
tendinous  insertions  of  the  muscles,  especially  of  the  masseter, 
and  it  is  owing  to  the  action  of  the  latter  muscle  that  the 
margin  of  the  ramus  is  everted.  As  these  muscles  atrophy 
and  become  almost,  if  not  completely,  functionless,  the 
portions  of  the  bone  into  which  they  are  inserted  lose  their 
prominent  ridges  and  their  everted  margin,  and  become 
rounded  and  wasted  in  a  manner  similar  to  that  in  which  the 
portion  of  the  great  tuberosity  of  the  humerus,  which  receives 
the  insertion  of  the  supra-spinatus,  atrophies  in  feeble  old  age. 
It  is  this  atrophy  of  the  angle  which  causes  the  appearance  of 
the  jaw  peculiar  to  edentulous  old  age.  The  atrophy  of  the 
fibro-cartilage  is  due  partly  to  an  atrophy  common  to  it  and 
the  muscle  inserted  into  it,  and  partly  to  the  loss  of  the  move- 
ments of  flexion  of  the  temporo-maxillary  articulation,  and  to 
their  replacement  by  a  simple  antero-posterior  movement  of 
the  opposing  surfaces  of  bone  upon  one  another.  After  the 
fibro-cartilage  is  removed,  the  articular  cartilage  is  also 
destroyed,  the  surfaces  of  bone  being  brought  into  direct  con- 
tact. By  their  mutual  friction  they  destroy  one  another, 
and  the  amount  of  destruction  will  depend  on  the  amount  and 
character  of  the  movement  to  which  the  bones  are  exposed, 
and  the  vitality  of  the  osseous  and  nervous  systems." 

Titbercular  Disease. — This  is  a  very  rare  disease  and  but 
few  cases  are  recorded.  In  his  "  Practical  Observations  in 
Surgery"  (18 16),  Mr.  John  Ho wship  describes  a  case  of 
"  scrofulous  inflammation  of  the  face,  followed  by  ankylosis  of 
the  jaw  "  in  a  man  of  fifty-six  years  of  age,  who  dated  the 
origin  of  the  disease  from  a  cold  taken  at  the  age  of  four. 
The  original  illustration  shows  complete  bony  ankylosis  of 
the  lower  jaw  to  the  temporal  bone  on  the  left  side.  On 
the  right  side  the  shape  of  the  joint  is  considerably  modified, 
as  may  be  seen  in  the  specimen  in  the  College  of  Surgeons' 

2  B 


386     DISEASES    OF    THE    TEMPORO-MAXILLARY    ARTICULATION. 

Museum.  Lannelongue  has  reported  a  case  of  tuber- 
cular disease  in  which  the  condyle  became  separated  from 
the  rest  of  the  bone,  passed  into  the  auditory  meatus  and 
penetrated  into  the  cranial  cavity,  causing  an  abscess  of  the 
brain  (Bull,  de  la  Soc.  Anat.,  1866). 

Treatment. — The  treatment  of  acute  arthritis  of  the 
temporo-maxillary  joint  is  similar  to  that  of  acute  arthritis 
of  any  other  joint.  Eest  is  the  first  consideration,  but 
absolute  rest  is  very  difficult  to  obtain  in  the  case  of  the 
lower  jaw.  The  application  of  an  elastic  bandage,  except 
when  food  is  being  taken,  will  be  of  some  service. 

Dr.  Groodwillie,  of  New  York,  has,  however,  contrived  an 
ingenious  method  of  fixing  the  lower  jaw  effectually  in 
cases  of  arthritis,  which  will  be  best  described  in  his  own 
words  {Archives  of  Medicine,  New  York,  June,  1 8  8 1 )  : 

"  The  method  that  I  employ  is  as  follows  :  In  this  case 
the  patient  is  under  the  angesthetic  effect  of  morphine  and 
nitrous  oxide.  If  there  is  any  rigidity  of  the  muscles,  I 
cautiously  force  open  the  mouth  and  take  an  impression  of 
eitlier  the  upper  or  lower  teeth,  and  a  rubber  splint  is  made 
from  the  cast  to  cover  over  all  the  teeth  in  one  jaw.  Upon 
the  posterior  part  of  this  splint  is  made  a  prominence  or 
fulcrum  (-D),  so  that  when  the  mouth  is  closed  the  most 
posterior  teeth  close  upon  it,  while  all  the  anterior  teeth  are 
left  free.  The  next  step  is  to  take  a  plaster  of  Paris  im- 
pression of  the  chin,  and  from  this  make  a  splint  {A).  On 
each  end  of  the  splint  is  made  a  place  for  fastening  elastic 
straps  {B)  that  pass  up  on  each  side  of  the  head  to  a  close- 
fitting  skull-cap  (C).     (Fig.  172.) 

"  When  the  apparatus  is  in  place  and  the  elastic  straps 
tightened  so  as  to  lift  the  chin,  then  pressure  is  brought  to 
bear  on  the  fulcrum  at  the  posterior  molar  tooth,  and  so  by 
this  means  extension  is  made  at  the  joints,  and  the  inflamed 
surfaces  within  the  joints  are  relieved  from  pressure  ;  then 
immediate  relief  is  experienced." 

In  the  non-suppurative  cases,  after  the  acute  symptoms 
have  subsided,  counter-irritation  by  means  of  blisters  or 
iodine,  and  gentle  massage  over  the  joint  may  be  iiseful. 


SUB-LUXATION    OF    TEMPOKO-M AXILLARY   JOINT. 


387 


Especial  care  should  be  taken  to  prevent  fibrous  adhesions 
forming.  This  result  is  best  avoided  by  passive  movements 
of  the  joint. 

In  cases  of  suppurative  arthritis  it  is  important  to  give 
exit  to  the  pus  as  soon  as  possible.  If  this  is  not  done  the 
pus  may  burrow  widely  into  neighbouring  structures,  es- 
pecially into  the  ear,  causing  otitis  media.     In  some  cases 

Fig.  172. 


the  pus  bursts  into  the  auditory  canal  externally  to  the 
membrane,  and  discharges  itself  through  the  external 
meatus. 

In  cases  of  chronic  arthritis  rest  is  an  important  factor 
in  tiie  treatment,  and  should  be  combined  with  counter- 
irritation. 

In  tulercular  disease,  after  rest  has  been  tried  without 
success,  the  joint  should  be  opened  and  all  the  tubercular 
material  removed — in  fact,  the  operation  of  arthrectomy 
should  be  performed.  If  the  condyle  be  found  seriously 
diseased  it  should  be  removed  and,  if  necessary,  the  glenoid 
fossa  should  be  thoroughly  scraped. 

Suh-luxation  of  the  Tem;poro-maxillary  Joint. — This  was  the 
only  disease  of  the  joint  recognised  by  the  older  surgical 


o88       DISEASES  OF  THE  TEMFORO-MAXILLARY  AETICULATIOE". 

authors,  and  the  term  '  sub-luxation '  was  applied  to  it  by 
Sir  Astley  Cooper.  It  is  an  affection  occurring  principally 
in  delicate  women,  and  has  been  thought  to  depend  upon 
relaxation  of  the  ligaments  of  the  joint  permitting  a  too 
free  movement  of  the  bone,  possibly  a  slipping  of  the  inter- 
articular  cartilage. 

From  a  considerable  acquaintance  with  this  affection,  I 
believe  that  it  is,  in  many  cases  at  least,  unconnected  with 
any  slipping  of  the  cartilage,  but  is  due  to  rheumatic  or 
gouty  changes  in  the  articulation.  The  fact  that  these 
patients  suffer  most  in  damp  weather  and  when  the  general 
health  is  feeble,  shows  that  it  depends  upon  arthritic  diathesis, 
and  the, relief  that  is  obtained  from  counter-irritation  and 
the  exhibition  of  anti-rheumatic  or  anti-gouty  remedies, 
proves  that  the  complaint  cannot  be  always  due  to 
purely  mechanical  causes.  Professor  Annandale,  of  Edin- 
burgh, however,  believes  that,  as  in  the  case  of  the  semilunar 
cartilages  of  the  knee,  the  inter-articular  cartilage  of  the 
temporo-maxillary  joint  may  become  displaced  either  by  a 
sudden  tearing  of  its  connections  or  by  a  gradual  stretching  of 
them.  In  order  to  remedy  the  displacement,  Mr.  Annandale 
has  devised  and  practised  the  following  operation  :  An  incision, 
slightly  curved,  about  three-quarters  of  an  inch  in  length,  is 
made  over  the  posterior  margin  of  the  external  lateral 
ligament  of  the  temporo-maxillary  joint,  and  is  carried  down 
to  its  capsule.  Any  small  bleeding  vessels  having  been 
secured  the  capsule  is  divided,  and  the  inter-articular  car- 
tilage is  seized,  drawn  into  position,  and  secured  to  the 
periosteum  and  other  tissues  at  the  outer  margin  of  the 
articulation  by  a  catgut  suture.     {Lancet,  Feb.  26th,  1887.) 


CHAPTER  XXIV. 

CLOSUEE    OF    THE    JA.W. 

By  the  term  '  closure  of  the  jaw  '  is  meant  a  condition  in 
which  the  lower  jaw  cannot  be  properly  depressed.  This 
inability  to  move  the  jaw  may  vary  in  degree.  In  some  cases 
there  is  complete  immobility ;  in  other  cases  the  jaw  can  be 
depressed  to  a  varying  amount.  The  causes  of  this  fixation 
are  numerous  and  differ  widely  in  their  nature.  They  may  be 
conveniently  classified  in  the  following  manner : 

(a)  Spasmodic  or  Temporary  Closure  of  the  Loiver  Jaio. — 
This  may  be  only  a  symptom  of  some  disease  affecting  the 
central  nervous  system,  such  as  tetanus,  or  of  some  cerebral 
disease  ;  in  women  it  has  been  met  with  as  a  symptom  of 
hysteria.  The  most  common  cause  is  some  inflammation  in 
the  neighbourhood  of  the  lower  jaw,  or  in  the  lower  jaw 
itself,  thus,  mumps  and  inflammation  of  the  lymphatic 
glands  of  the  neck  are  frequent  causes.  This  condition 
may  be  caused  by  impeded  eruption  of  the  wisdom  teeth 
of  the  lower  jaw.  Owing  to  want  of  room  between  thti 
second  molar  and  the  ramus  of  the  jaw,  or  owing  to  some 
malposition  of  the  tooth  itself,  the  wisdom  tooth  is  unable 
to  assume  its  normal  position,  and  by  the  pressure  which  it 
exerts  on  the  neighbouring  structures,  sets  up  irritation, 
which  induces  a  state  of  tonic  spasm  of  the  masseter  and 
internal  pterygoid  muscles.  This  fact  has  long  been  known 
to  dental  surgeons,  and  is  especially  alluded  to  by  Mr.  Salter 
in  his  essay  on  Surgical  Diseases  connected  with  the  Teeth. 
('System  of  Surgery,'  vol.  ii). 

The  accompanying  engraving  (Fig.  173),  for  which  I  am 
indebted  to  Mr.  Felix  Weiss,  shows  the  condition  of  parts 


390 


CLOSUKE    OF    THE   JAW. 


found  by  him  in  a  gentleman,  aged  forty-three,  who  suffered 
long  and  severely  from  pain  and  spasmodic  closure  of  the 
jaws,  due  to  the  irritation  caused  by  the  wisdom  tooth  lying 
imbedded  horizontally  in  the  alveolus,  and  pressing  against 
the  fang  of  the  second  molar.  It  was  only  after  the  extrac- 
tion of  the  second  molar  that  the  wisdom  tooth  was  found 
and  removed,  with  complete  relief  of  the  symptoms  {Trans. 
Odontological  Society,  1876). 

In  a  discussion  which  took  place  at  the  Odontological 
Society,  in  May,  1861,  and  is  reported  in  the  British 
Journal  of  Dental  Science  of  the  same  month,  Mr.  Tomes 

Fig.  173. 


mentioned  a  case  of  retarded  eruption  of  the  wisdom  tooth 
with  closure  of  the  jaws,  which  had  been  allowed  to  go 
unrelieved  for  more  than  two  years,  and  was  immediately 
cured  by  the  removal  of  the  second  molars,  so  as  to  allow 
the  wisdom  teeth  to  assume  their  proper  position.  Mr. 
Coleman,  Mr.  Mummery,  and  Mr.  Ibbetson  narrated,  on 
the  same  occasion,  very  similar  cases  treated  in  the  same 
manner;  and  Mr.  Drew  mentioned  a  case  in  which  extrac- 
tion of  the  half-cut  wisdom  tooth  itself  gave  immediate 
relief. 

The  majority  of  these  cases  occur  about  the  age  of 
twenty,  when  the  eruption  of  the  wisdom  tooth  is  to  be  ex- 
pected, and  the  diagnosis  is  readily  made.  The  treatment 
is  obvious.  The  mouth  must  be  opeiied  by  a  screw  gag,  or 
by  a  spiral  screw  wedge  of  boxwood,  under  chloroform,  and 


PEKMANENT    CLOSURE    OF    THE   JAW.  391 

either  room  must  be  made  for  the  wisdom  tooth  by  extracting 
the  second  molar,  or,  if  it  can  be  reached,  the  wisdom  tooth 
itself  may  be  removed. 

The  impeded  eruption  of  wisdom  teeth  gives  rise  to  various 
and  apparently  anomalous  symptoms,  which  are  often  not 
traced  to  their  true  source,  such  as  persistent  neuralgia,  not 
always  referred  to  the  part  involved  ;  but  the  most  serious 
result  is  the  formation  of  extensive  abscesses,  which  burrow 
widely  about  the  angle  of  the  jaw  and  cheek,  leading  to 
great  scarring  and  permanent  deformity.  In  a  young  lady, 
seen  by  me  in  consultation  some  years  back,  the  mischief 
resulting  from  an  impacted  wisdom  tooth  was  sufficient  to  put 
her  life  in  some  jeopardy,  and  has  left  her  face  permanently 
scarred  by  extensive  abscesses. 

The  pathology  of  these  spasmodic  cases  is  by  no  means 
clear.  In  some  cases  it  appears  to  be  purely  a  reflex  spasm 
of  the  muscles,  the  afferent  stimulus  being  caused  by  the 
inflammatory  focus.  In  other  cases,  however,  the  inflamma- 
tion seems  to  spread  to  the  muscles,  causing  a  myositis.  As 
a  rule  this  myositis  subsides  as  soon  as  the  inflammatory 
mischief  ceases ;  in  some  cases,  however,  the  myositis  causes 
a  permanent  contraction  of  the  muscles. 

The  treatment  of  this  condition  is  obvious.  The  exciting 
cause  must  be  determined  and  dealt  with,  and  later  efforts 
should  be  made  to  prevent  any  permanent  changes  in  the 
muscles  by  systematic  massage,  &c. 

(&)  Permanent  Closure  of  the  Loiver  Jnir. — The  causes  of 
this  condition  may  be  divided  into  two  main  groups  ;  those 
caused  by  diseases  of  the  temporo-maxillary  joint,  and  those 
caused  by  cicatricial  bands  within  the  mouth. 

I.  Ankylosis  of  the  Joint. — In  the  cases  of  fibrous  ankylosis 
resulting  from  the  cure  of  arthritis,  it  is  open  to  the  surgeon 
to  have  recourse  to  mechanical  means  to  break  down  the 
adhesions  ;  and  to  illustrate  the  diificulties  to  be  overcome,  I 
may  refer  to  another  case  of  Dr.  Goodwillie's  {New  York 
Medical  Journal,  July,  1875):  The  patient  was  a  girl  of 
ten,  who,  five  years  before,  had  fallen  over  the  bannisters, 
breaking  and  dislocating  the  jaw,  with  the  result  of  the  jaws 


392 


CLOSURE    OF    THE    JAW, 


being  firmly  closed.    The    apparatus   employed  is   seen  in 
Fig.  174. 

One  of  the  chief  sources  of  interruption  in  treatment  is 
periodontitis  from  the  great  amount  of  force  used  on  the 
teeth.  To  prevent  this,  Dr.  Groodwillie  protects  them  with 
an  interdental  splint  of  hard  rubber.  These  splints  at  first 
are  necessarily  very  small,  and  confined  to  the  front  teeth  ; 
but,  as  the  case  progresses,  longer  and  more  perfect  ones  are 
made.  In  this  case  the  rubber  splints  were  enclosed  in 
metal  splints  made  of  German  silver,  as  this  metal  is  tough 
and  unyielding.  These  splints  were  made  fast  to  the  teeth 
by  straps  that  passed  from  strong  wire  arms  at  the  sides  to 

Fig.  174. 


a  skull-cap,  and  the  lower  one  was  strapped  to  a  pad  on  the 
chin.  This  pad  was  also  attached  to  the  lower  splint  by 
means  of  a  ratchet  and  spring. 

From  the  point  of  each  splint  an  arm,  three-fourths  of 
an  inch  broad,  extends  out  one  and  a  quarter  inch,  and  to 
these  is  clasped  the  oral  speculum  when  in  use  (Fig.  1 74). 
The  inclined  planes  of  the  speculum  pass  in  between  these 
arms,  and  they  are  held  by  clasps.  The  inclined  planes 
are  attached  by  movable  joints  to  a  distending  forceps,  so 
that  when  the  handles  are  approximated,  the  inclined  planes 
are  separated  at  their  attached  ends.  Each  handle  is  made 
in  two  sections,  and  the  spring  that  separates  the  handle  is 
enclosed  between  them  to  protect  them  from  injury. 

In  forcing  the  speculum  between  the  splints,  the  instru- 
ment is  grasped  by  one  of  the  handles,  and  when  in  place 
both  handles  are   approximated.      If  more  force  is  desired 


DIVISION    OF    ADHESIONS.  6^6 

or  the  mouth  is  to  be  held  open  at  any  point,  the  screv7  at 
the  handle  may  be  used. 

In  stretching  the  masseter  and  temporal  muscles,  Dr. 
Goodwillie  uses  an  oral  speculum,  devised  by  him  some 
years  ago  (Fig.  175).  It  consists  of  a  shaft,  to  the  flat  end 
of  which  are  attached  two  wings  or  inclined  planes,  upon 
which  the  teeth  rest.  The  other  end  of  the  shaft  has  a 
thread  cut  on  it,  and  a  screw  ;  this  passes  through  a  handle, 
one  end  of  which  is  wedge-shaped.  By  turning  the  screw 
on  the  other  end  of  the  handle,  the  inclined  planes  diverge 
or  converge.  Fig.  176  represents  a  spiral-spring  speculum 
for  the  patients  to  employ  by  placing  it  between  the  teeth 


Fig.  175. 


Fig.  176. 


and  biting  upon  it.  Longer  springs  are  used  as  the  mouth 
gradually  opens. 

It  need  hardly  be  said  that  treatment  by  this  method 
would  extend  over  many  months,  and  would  severely  try  tlie 
endurance  of  both  patient  and  surgeon. 

A  simpler  method  is  the  division  of  adhesions  formed 
between  the  condyle  and  glenoid  cavity,  as  practised  by  Mr. 
Spantou.  Believing  that  the  immobility  was  dependent  on 
an  ankylosis  of  the  temporo-maxillary  joints,  with  probable 
contraction  of  the  ligaments  surrounding  them,  and  failing  to 
make  the  slightest  impression  by  means  of  a  gag  with  any 
justifiable  amount  of  force,  Mr.  Spanton  passed  a  very  narrow 
tenotomy  knife  into  the  temporo-maxillary  joint  on  each 
side,  immediately  in  front  of  the  temporal  artery,  and  then 
carried  it  freely  round  the  condyle  of  the  inferior  maxilla  as 
far  as  he  deemed  prudent,  dividing  completely  the  external 
lateral  ligament  of  the  joint,  and  partially  the  insertion  of 


394  CLOSURE    OF    THE    JAW. 

the  external  pterygoid  muscle,  keeping  the  back  of  the  knife 
towards  the  temporal,  and  carefully  measuring  the  depth  of 
the  incision  so  as  to  avoid  the  middle  meningeal  artery. 
Very  little  heemorrhage  occurred ;  and  as  soon  as  this  pro- 
cedure was  effected,  Mr.  Spanton  found  that  the  joints 
yielded  at  once  to  the  gag,  and  that  the  mouth  could  be 
opened  to  the  extent  of  more  than  an  inch.  For  a  day  or 
two  some  soreness  was  complained  of,  but  the  gag  was  used 
almost  daily,  and  seven  weeks  afterwards  the  patient  left  the 
infirmary  able  to  open  the  mouth  fairly  well  and  to  masticate 
her  food.  The  result  proved,  however,  disappointing,  as 
re-contraction  took  place,  and,  in  fact,  one  of  the  two 
patients  operated  on  subsequently  came  under  my  own  care 
for  closure. 

In  cases  of  fibrous  ankylosis  there  is  the  possibility  of  re- 
moving the  condyle,  as  has  been  done  by  Mr.  Davies-Colley, 
Mr.  Barker  and  others  ;  or,  as  proposed  by  Dr.  Ewing  Mears 
(American  Journal  of  Medical  Science,  October,  1883),  of 
dividing  the  ramus  of  the  jaw,  and  excising,  through  the 
mouth,  the  condyle  with  the  coronoid  process  and  sigmoid 
notch. 

Dr.  Mears'  operation  is  as  follows :  a  straight  sharp- 
pointed  bistoury  is  introduced  beneath  the  masseter  muscle, 
on  a  level  with  the  last  molar  tooth  of  the  lower  jaw.  Into 
the  wound  thus  made  the  blade  of  an  Adams'  saw  is  passed, 
and  the  ramus  sawn  through.  The  periosteum,  with  the 
overlying  masseter  muscle,  is  raised  by  the  periosteal  elevator, 
and  the  wo  and  thus  enlarged.  The  insertion  of  the  temporal 
muscle  is  now  divided  by  a  probe-pointed  bistoury.  The 
tissues  on  the  inner  surface  are  separated  by  the  elevator, 
the  bone  seized  by  the  lion -jawed  forceps,  and  an  effort  made 
to  dislodge  it  by  forcibly  twisting  it  outwards.  If  it  yields 
at  the  neck  of  the  condyle,  the  process  is  afterwards  chiselled 
out.  If  sufficient  space  is  acquired  without  removal  of  the 
firmly  ankylosed  process,  it  is  permitted  to  remain,  the  object 
being  to  provide  ample  space  for  the  formation  of  an  artificial 
joint.  Section  of  the  masseter  muscle  is  made,  if  its  tense 
condition  demands  it.      Haemorrhage,  which  arises  from  the 


EXCISIOX    OF    THE    CONDYLE.  :595 

division  of  muscular  arterial  branches  and  possibly  of  the 
inferior  dental  artery,  is  controlled  by  pressure  effected  by 
packing  the  wound  cavity  with  sponges.  Wounding  of  the 
internal  maxillary  artery  is  to  be  avoided  by  careful  use  of 
the  instrument  in  close  contact  with  the  l^one  in  the  upper 
and  inner  portions. 

A  case  of  the  removal  of  both  condyles  for  fibrous  anky- 
losis is  quoted  by  the  Wiener  Med.  Woche7ischriff,  of  July 
6th,  1872,  from  the  proceedings  of  the  Eoyal  Academy  of 
Medicine  in  Bologna.  In  occurred  in  the  practice  of  Dr. 
Bottini.  The  patient  was  a  lad,  aged  seventeen,  who,  at  the 
age  of  seven,  had  fallen  on  the  jaw,  and  had  gradually  lost  the 
power  of  opening  his  mouth,  so  tliat  at  last,  for  some  months, 
he  was  unable  to  separate  the  jaws  to  any  extent.  Dr.  Bottini 
introduced  wedges,  but  these  were  very  irksome  to  the  patient 
and  were  removed.  Ptesection  of  the  articular  head  of  the 
bone  was  then  performed  on  one  side  ;  this  had  no  noticeable 
result,  but  on  the  operation  being  repeated  on  the  other  side, 
the  jaw  could  be  moved  freely.  At  the  end  of  six  weeks  the 
wound  had  healed,  and  the  motion  of  the  jaw  was  normal. 
The  only  morbid  change  that  could  be  discovered  was  the 
absence  of  the  inter-articular  fibro-cartilacre. 

In  cases  of  rheumatoid  arthritis  in  which  the  suffering  is 
great,  excision  of  the  condyle  seems  to  offer  the  best  means 
of  giving  relief.  The  first  removal  of  the  condyle  was  by  Pro- 
fessor Humphry,  of  Cambridge  (Med.  Association  Jonrnal 
1856),  and  was  undertaken  for  chronic  rheumatic  arthritis. 
He  exposed  the  condyle  by  a  curved  incision  from  the  side  of 
the  orbit  across  the  zygoma  to  the  ear,  passing  a  little  above 
the  temporo-maxillary  articulation,  and  a  second  incision  from 
the  termination  of  the  first  directly  upwards  in  front  of  the 
ear  across  the  zygoma  again,  avoiding  the  temporal  artery. 
The  flap  thus  made  was  reflected,  and  the  neck  of  the 
condyle  cut  through  with  a  narrow  saw. 

In  cases  of  complete  fixation  also,  resection  of  the  condyle 
lias  been  frequently  adopted  by  various  surgeons.  In 
1874  Dr.  Gross,  of  Philadelphia,  resected  the  condyle 
witli    a   portion   of   the  neck   of    the  jaw  in  a  girl,  aged 


396  CLOSURE    OF    THE    JAW. 

seven,  but  does  not  mention  the  method  he  pursued.  Mr. 
Croft  resected  the  condyle  on  both  sides  consecutively  in  a 
child  with  good  results ;  and  Mr.  Davy,  of  the  Westminster 
Hospital,  removed  a  condyle  from  two  patients  with  the 
best  results.  Mr.  Davy's  first  case  was  in  a  woman,  aged 
fifty,  who  had  complete  closure  of  the  jaws,  and  from  whom 
the  left  condyle  was  removed  in  October,  1878.  She  made 
a  rapid  recovery,  with  perfect  mastication,  but  died  from  the 
bursting  of  an  aortic  aneurysm  on  December  8th,  and  the 
remainder  of  the  jaw  was  then  obtained.  Mr.  Davy's 
second  case  was  in  a  man,  aged  forty-seven,  who  perfectly 
recovered. 

In  1883  I  exposed  theankylosed  joint  in  a  boy,  aged 
seven,  by  an  incision  in  front  of  the  ear,  and  with  a  chisel 
divided  the  neck  of  the  bone,  and  removed  half  an  inch  of 
bone  in  the  situation  of  the  condyle,  with  very  good  results 
as  regards  movement,  and  with  no  obvious  damage  to  the 
facial  nerve.  Mr.  Barker  also  published  a  very  successful 
case  with  illustrations  in  the  Lancet,  May  20th,  1893. 

A  case  of  complete  synostosis  of  the  jaw  was  successfully 
treated  by  a  different  method  by  Dr.  James  Little,  of  New 
York,  in  1873.  The  patient  was  aged  nineteen,  and  had 
some  years  before  suffered  from  suppuration  of  the  temporo- 
maxillary  articulation,  leading  to  ankylosis.  Dr.  Little 
made  an  incision  along  the  lower  border  of  the  jaw,  and 
turned  up  the  masseter,  when  the  neck  of  the  condyle  was 
seen  to  be  very  much  enlarged,  and  continuous  with  the 
temporal  bone.  A  half-inch  trephine  was  then  applied,  and 
a  button  of  bone  three-eighths  of  an  inch  in  thickness 
was  removed.  The  portion  of  bone  on  each  side  of  the 
opening  was  then  cut  through  with  a  chisel,  and  the  neck  of 
the  condyle  cut  away  piece  by  piece,  so  as  to  leave  no  portion 
projecting  from  the  temporal  bone.  The  result  was  quite 
satisfactory. 

A  similar  operation,  but  performed  by  a  different  method, 
was  successfully  undertaken  by  Dr.  Eobert  Abbe,  of  ISTew 
York,  in  a  boy,  aged  ten,  who  had  suffered  from  otitis  media 
and  suppuration  of  the  joint  some  years  before.      A  vertical 


DIVISION    OF    THE    KAMUS.  o97 

incision  was  made  in  front  of  the  ear,  and  a  horizontal  one 
meeting  its  upper  end  was  carried  along  the  lower  border  of 
the  zygoma.  The  parotid,  with  the  facial  nerve,  was  drawn 
down,  and  with  a  periosteal  elevator  the  posterior  fibres  of 
the  masseter  were  cleared  away,  and  the  articulation  exposed. 
A  narrow  osteotomy  chisel  was  now  applied  to  the  neck  of 
the  condyle,  and  carefully  driven  half  through  the  bone, 
and  by  forcibly  opening  the  mouth  the  bone  was  broken 
through.  The  neck  of  the  condyle  was  then  removed  piece- 
meal, but  the  condyle  was  left  in  situ.  The  result  was 
satisfactory. 

Sedillot  mentions  that  in  a  case  of  true  ankylosis  of  the 
temporo-maxillary  articulation,  M.  Grube,  in  1863,  carried 
a  straight  chisel  through  the  mouth  to  the  neck  of  the  jaw, 
which  broke  by  hammering.  Some  months  later,  he  divided 
the  masseter  subcutaneously,  and  the  cure,  by  the  formation 
of  a  false  joint,  was  permanent.  In  1879  I  performed  the 
same  operation  in  a  child,  aged  six,  but  the  results  were  un- 
satisfactory. Suppuration  was  set  up,  and  required  an 
external  opening,  and  the  movement,  which  was  free  at  first, 
became  as  limited  as  before  the  operation,  and  I  subsequently 
excised  the  condyle.  It  would  appear,  therefore,  that  mere 
division  of  the  neck  of  the  bone  does  not  offer  such  cfood 
prospect  of  a  permanent  false  joint  as  removal  of  the  neck 
or  the  condyle,  though  these  operations  are  necessarily  more 
severe. 

In  1 8 36  I  performed  an  operation  which  appeared  to 
me  to  possess  advantages  over  other  proceedings  under- 
taken for  ankylosis  of  the  temporo-maxillary  articulation, 
and  which  consists  in  the  division  of  the  ramus  of  the  lower 
jaw  beneath  the  masseter  by  a  saw  introduced  from  the 
mouth.  The  patient  was  a  young  gentleman,  aged  sixteen, 
who  came  under  my  care  with  complete  closure  of 
the  jaws  due  to  ankylosis  of  the  left  temporo-maxillary 
articulation.  He  had  scarlet  fever  in  1881,  and  the  disease 
followed  upon  this.  In  1882,  and  twice  in  1883,  attempts 
were  made  to  screw  the  mouth  open,  with  only  partial  and 
very  temporary  success ;  and  when  I  saw  him,  the  appli- 


398  CLOSUKE   OF    THE    JAW. 

cation  of  a  powerful  screw-gag  produced  no  effect.  In 
December  1886  I  made  a  small  incision  within  the  mouth 
immediately  above  the  last  molar  tooth,  and  having  passed 
a  steel  director  to  clear  the  way,  I  was  able  to  push  an 
Adams'  saw  beneath  the  masseter  and  to  divide  the  ramus 
horizontally.  No  haemorrhage  occurred  from  the  inferior 
dental  artery,  though  the  accompanying  nerve  was  sub- 
sequently found  to  have  been  damaged. 

The  patient  was  able  to  open  his  mouth  as  soon  as  he 
recovered  from  the  chloroform,  and  made  a  rapid  recovery. 
Unfortunately,  he  caught  cold  on  the  railway  journey  home, 
and  an  abscess  formed  and  pointed  behind  the  jaw,  but 
left  only  a  dimple.  The  result,  however,  was  not  satis- 
factory, as  re-contraction  steadily  took  place,  and  nearly  two 
years  later  I  repeated  the  proceeding  with  more  lasting 
benefit.  In  1887  I  adopted  the  same  method  in  a  young 
lady  who,  by  dint  of  great  perseverance  in  the  use  of  a 
screw-gag,  has  maintained  a  good  amount  of  movement; 
but  in  a  youth  of  sixteen,  in  whom  I  also  operated,  the 
closure  became  so  complete  that  I  had  recourse  to 
Esmarch's  operation,  and  removed  a  wedge  of  bone  with 
good  results. 

In  a  few  cases  of  bilateral  ankylosis  it  has  been  thought 
advisable  to  perform  Esmarch's  operation  on  both  sides  of 
the  jaw.  Thus,  Dr.  Maas,  of  Breslau,  relates  in  the  Arcliiv 
filr  Klin.  Chirurg.  (Band  xiii,  Heft  3)  the  case  of  a  man,  aged 
twenty-seven,  who  was  admitted  into  hospital  with  ankylosis 
of  the  jaw  on  both  sides.  It  had  come  on  after  an  attack  of 
scarlet  fever  when  he  was  seven  years  old,  being  preceded 
by  severe  pain  in  the  part ;  and  since  the  age  of  ten  he  had 
not  been  able  to  move  the  jaw  at  all.  The  secondary 
dentition  was  attended  with  great  difficulty  in  the  removal 
of  the  milk  teeth ;  and  the  new  teeth  were  irregularly 
developed,  and  for  the  most  part  were  displaced  laterally. 
The  patient,  on  admission,  was  of  anaemic  appearance,  though 
in  moderately  good  condition;  the  lower  jaw  was  imperfectly 
developed.  Speech  was  somewhat  muffled,  but  was  quite 
intelligible.      Not  the  least  movement  of  the  jaw  could  be 


BI-LATKRAL    ESMARCH.  o99 

produced  under  anaesthesia.  Herr  Middeldorpf  operated  on 
the  right  side,  removing  a  wedge-shaped  piece  of  bone,  as 
recommended  by  Esmarch,  near  the  angle.  The  result  of 
this  was  the  formation  of  a  false  joint,  with  power  of 
opening  the  mouth  passively  to  the  extent  of  about  an  inch. 
Between  four  and  five  months  later,  Dr.  Fischer  performed  a 
similar  operation  on  the  left  side ;  four  months  after  this, 
the  patient  could  voluntarily  open  his  mouth  without  pain 
to  the  extent  of  about  an  inch. 

Mr.  W.  H.  Bennett  brought  before  the  Clinical  Society 
in  1889  a  very  remarkable  case  of  double  ankylosis  of  the 
jaw,  in  wJiich  another  surgeon  had  unsuccessfully  removed 
both  condyles  with  the  chisel  some  years  before.  Mr. 
Bennett  removed  both  angles  of  the  jaw  with  the  saw  after 
Esmarch's  method,  a  week  intervening  between  the  two 
operations,  and  the  patient  obtained  complete  power  of 
opening  his  mouth,  which  has  been  permanent.  Mr.  Bennett 
remarks : 

"  The  success  of  the  treatment  finally  adopted  seems  to  be 
due  partly  to  the  seat  of  the  operation  in  each  instance 
being  as  far  removed  as  possible  from  the  temporo-maxillary 
articulation,  but  more  particularly  to  the  fact  that,  by  the 
excision  of  the  angles  of  the  jaw,  it  was  easy  to  be  sure 
that  the  masseter  and  internal  pterygoid  muscles  were 
permanently  separated  from  the  central  part  of  the  bone,  a 
matter  of  some  importance,  in  my  opinion ;  since  it  is 
obvious  that  if  these  muscles  be  left  in  any  way  attached 
to  the  lower  part  of  the  jaw,  after  its  division,  they  will 
tend,  no  matter  how  large  a  piece  of  bone  may  be  excised, 
to  elevate  the  lower  fragment  and  approximate  the  cut 
surfaces  ;  so  inclining,  in  spite  of  passive  motion,  to  the 
direct  production  of  osseous  union  in  cases  in  which  the 
tendency  to  bone  formation  is  at  all  excessive,  a  circum- 
stance which  is,  I  believe,  sufficient  to  account  for  the 
difficulties  not  infrequently  met  with  in  attempts  to  produce 
false  joints  in  the  lower  jaw  by  operations  limited  to  the 
portion  of  that  bone  situated  above  the  angle."  {Clinical 
Society's  Transactions,  vol.  xxii.) 


400  CLOSUEE    OF    THE    JAW. 

2.  Closure  (if  ilic  Jaio  from  Cicatrices. — The  majority  of 
cases  of  permanent  closure  of  the  jaw  are  caused  by  cica- 
trices situated  within  the  mouth.  The  constricting  band 
may  be  limited  to  the  mucous  membrane  or  may  be  attached 
to  the  bone,  forming  a  firm  bond  of  union  between  the  two 
jaws.  These  scars  are  generally  caused  by  extensive  ulcer- 
ative or  gangrenous  conditions  of  the  mouth.  According  to 
Dr.  Gross,  of  Philadelphia,  the  most  common  cause  is  pro- 
fuse ptyalism,  followed  by  gangrene  of  the  cheeks,  lips,  and 
jaw,  and  the  formation  of  firm,  dense,  unyielding,  inextensile 
tissue,  by  which  the  lower  jaw  is  closely  and  tightly  pressed 
against  the  upper.  Such  an  occurrence  used  to  be  ex- 
tremely frecjuent  in  the  south-western  States  during  the 
prevalence  of  the  calomel  practice,  as  it  was  termed,  but  is 
now,  fortunately,  rapidly  diminishing. 

In  children,  especially  of  the  poorer  classes,  ulcerative 
stomatitis  and  cancrum  oris,  which  may  arise  during  the 
course  of  measles  or  scarlet  fever,  are  the  most  frequent 
causes. 

In  rare  cases  the  cicatrix  may  be  the  result  of  a  compound 
fracture,  or  a  lacerated  wound,  or  may  foUov/  some  surgical 
operation  on  the  face  or  jaws. 

The  treatment  of  this  condition  is  often  very  unsatisfactory. 
Attempts  should  be  made  to  stretch  the  cicatricial  bands 
by  mechanical  means  such  as  have  been  described  in  the 
treatment  of  fibrous  ankylosis  of  the  temporo-maxillary 
joint  (see  p.  3^92). 

Division  of  the  cicatricial  bands,  either  by  subcu- 
taneous tenotomy  or  by  the  open  method,  is  sometimes 
followed  by  success  ;  but,  in  order  that  the  improvement 
may  be  permanent,  mechanical  dilatation  should  be  employed 
as  well. 

The  treatment  of  cicatricial  contraction  within  the  mouth, 
by  simple  division,  has  been  proved  over  and  over  again  to 
be  worse  than  useless.  The  difficulties  experienced  in  these 
cases,  and  the  failures  which  so  often  accompany  the  methods 
employed,  induced  Dr.  Ewing  Mears,  of  Philadelphia,  to 
make  an  effort  to  effect  division  of    the  dense  tissue  by 


CLOSUEE  FEOM  CICATRICES.  401 

means   of  a  ligature,  believing  that  reunion  could  thus  be 
partially,  if  not  completely,  prevented. 

Having  armed  a  strong-handled  needle  with  a  double- 
twisted,  carbolised  silk  ligature,  Dr.  Mears  passed  it  from 
the  angle  of  the  mouth  backward  between  the  integument 
and  the  outer  surface  of  the  cicatricial  mass,  and  caused  the 
point  to  emerge  just  behind  the  last  molar  tooth  of  the 
lower  jaw.  In  this  manner  he  surrounded  the  cicatricial 
tissue  with  the  ligature,  which  was  tied  loosely  and  moved 
each  day  for  a  week,  so  as  to  establish  a  canal  which  would 
not  readily  close.  At  the  expiration  of  a  week,  Dr.  Mears 
tightened  the  ligature  slightly,  and  every  third  day  for  the 
next  two  weeks  made  slight  torsion,  passing  a  probe  mean- 
while along  the  tract  of  the  ligature.  In  this  way  the 
dense  tissue  was  slowly  divided,  union  not  taking  place  at 
the  bottom  of  the  wound,  and  the  jaws  were  separated  three 
quarters  of  an  inch,  sufficient  for  all  practical  purposes. 
The  patient  went  to  his  home  in  the  country,  and  four 
months  later  returned  well. 

When  suitable  apparatus  is  adapted  to  the  jaws,  so  as  to 
prevent  re-contraction,  a  very  good  result  may,  with 
patience,  be  produced  in  cases  uncomplicated  by  destruc- 
tion of  the  cheek  itself.  Fig.  177  shows  a  sketch  of  the 
mouth  of  a  woman  who  had  cicatricial  bands  on  each  side, 
binding  the  cheeks  and  gums  together  so  that  she  was  able 
only  to  separate  the  lips,  and  in  whom  division  of  the 
cicatrices  had  been  practised  in  childhood.  The  lower  jaw 
was  edentulous,  but  the  upper  front  teeth  remained,  and 
Mr.  Felix  Weiss  succeeded  in  adapting  a  small  lower 
denture  so  as  to  antagonise  the  upper  teeth  and  prevent 
the  further  contraction  which  appeared  imminent,  at  the 
same  time  greatly  improving  the  patient's  power  of  articu- 
lation {British  Dental  Journal,  May,  1880). 

The  great  drawback  to  treatment  by  division  of  bands, 
and  one  with  regard  to  which  it  contrasts  unfavourably 
with  Esmarch's  proceeding,  is  the  amount  of  pain  which 
the  patient  must  of  necessity  undergo  during  the  after- 
treatment.     It  requires  no  small  amount  of  courage  on  the 

2  G 


402 


CLOSURE   OF    THE    JAW. 


part  of   the  patient,  and  some  determination  on  the  part  of 
the   attendant   to   carry  out   the    necessary  manipulations 

Fig.  177. 


within  the  mouth,  more  particularly  during  the  first  few 
days  after  the  operation ;  and  even  after  the  shields  are 
fitted    to   the    mouth,   they   cause   some   pain  and    incon- 

FlG.  178. 


venience,  to  which  only  those  who  have  arrived  at  years  of 
discretion  will  submit. 

Fig.  178  shows  the  form  of  the  silver  'shields' 
adapted  to  the  upper  and  lower  jaws  by  the  late  Mr. 
Clendon,     formerly    dental     surgeon    to    the    Westminster 


CLOSURE  FKOM  CICATRICES. 


403 


Hospital,  in  a  case  of  Mr.  Barnard  Holt's.  The  patient 
was  a  girl,  aged  seventeen,  and  was  under  Mr.  Holt's  care 
in  1862,  having  five  years  before  had  fever,  with  an 
abscess  of  the  cheek  on  the  right  side,  which  led  to  such 
contraction  and  adhesion  of  the  mucous  membrane  to  the 
jaw,  as  to  cause  great  difficulty  in  opening  the  mouth. 
Some  attempts  had  been  made  to  open  her  mouth  by  the 
screw,  &c.,  and  in  i860  Mr.  Holt  divided  some  of  the 
cicatrix  with  temporary  benefit.  Mr.  Holt  now  divided 
the  cicatrix  within  the  cheek  freely  under  chloroform,  and 

Fig.  179. 


encountered  a  firm  plate  of  bone  extending  between  the 
alveoli  of  the  two  jaws,  which  necessitated  the  use  of  a  saw 
for  its  division.  Mr.  Clendon  subsequently  fitted  the 
above-mentioned  shields  to  the  teeth,  and  wedges  were 
gradually  introduced  between  them  to  separate  the  jaws. 
This  treatment  was  continued  for  three  months,  when  she 
was  able  to  open  the  mouth  to  the  full  extent,  as  seen  in 
Fig.  179. 

At  the  Odontological  Society,  in  June,  1864,  Mr.  Cart- 
wright  narrated  a  very  similar  case  of  contraction  (with 
the  exception  that  there  was  no  bony  bridge  between  the 
alveoli)  in  a  woman,  aged  thirty-eight,  whom  he  successfully 
treated    by    similar    means,    using    wedges    of    vulcanised 


404  CLOSURE   OF   THE   JAW. 

india-rubber  affixed  to  the  shields  to  obtain  the  necessary 
extension. 

Subsequently  to  Mr.  Holt's  case,  I  had  under  my  care  a 
patient  with  a  very  severe  form  of  contraction,  namely,  on 
both  sides  of  the  mouth.  The  patient  was  aged  eighteen,  and 
the  contraction  dated  from  her  fifth  year,  when  she  had  fever. 
Various  attempts  had  been  made  to  give  her  relief  by  divid- 
ing the  cicatrices  and  using  wedges,  &c.,  without  benefit ; 
and  when  she  came  under  my  care  she  had  no  power  of 
separating  the  jaws  at  all,  and  the  cheeks  were  firmly 
attached  to  the  alveoli  from  the  angles  of  the  mouth. 
Having  secured  Mr,  Clendon's  co-operation,  I  freely  divided 
the  cicatrices,  and  after  repeated  trials  that  gentleman  suc- 
ceeded in  fitting  her  with  shields  resembling  those  used  in 
Mr.  Holt's  case,  but  reaching  over  both  sides.  It  was  found 
necessary  to  extract  all  the  teeth,  and  after  more  than  three 
months'  assiduous  care  and  frequent  modification  of  the 
shields,  the  patient  being  constantly  placed  under  the 
influence  of  chloroform  for  the  purpose,  a  very  satisfactory 
result  was  obtained,  there  being  exactly  one  inch  between 
the  metal  shields  in  the  incisive  region,  which  would 
have  left  about  half  an  inch  if  the  teeth  had  been  in 
siho. 

The  effect  of  the  use  of  shields  seems  to  have  been  not 
merely  to  prevent  adhesions  between  the  inside  of  the 
cheek  and  the  alveolus,  but  to  re-establish,  to  a  great 
extent,  the  sulcus  of  mucous  membrane  at  the  base  of  the 
alveolus,  upon  which  so  much  stress  is  laid  by  Professor 
Esmarch.  The  cause  of  non-success  in  former  attempts  at 
mechanical  appliances  is  to  be  found,  I  think,  in  the  fact 
that  they  have  all  been  directed  simply  to  keeping  the  jaws 
apart,  without  any  reference  to  the  re-establishment  of  the 
mucous  lining  of  the  cheek,  upon  which  the  movements 
of  the  jaw  so  much  depend. 

In  cases  where  the  closure  is  caused  by  contraction  of 
the  masseter  muscle,  the  operation  of  myotomy,  first 
described  by  Dieulafois  in  1838,  may  be  successful.  Le 
Dentu    suggests    that,  instead    of    dividing    the    masseter. 


ESMARCIl'S    OPERATION.  405 

the  insertion  of  that  muscle  should  be  re-implanted 
{SocieU  dc  Chirurgic,  1891). 

When  the  temporal  muscle  is  affected,  the  operation 
of  myotomy  is  not  recommended  because  of  the  severe 
hicmorrhage  that  may  ensue.  In  such  cases  division  of 
the  coronoid  process  is  a  more  satisfactory  proceeding. 

In  cases  where  the  skin  of  the  face  is  much  affected, 
certain  plastic  operations  may  be  necessary.  The  details  of 
the  operation  would  vary  so  much  in  different  cases  that  no 
definite  lines  could  be  laid  down. 

In  the  majority  of  cases  more  radical  treatment  has  to 
be  adopted,  and  Esmarch  was  one  of  the  first  to  describe  an 
operation  for  the  relief  of  this  condition. 

The  proposal  of  Professor  Esmarch  was  to  form  a  false  joint 
in  front  of  the  cicatrix,  and  it  was  suggested  to  him  by  a 
case  which  came  under  his  care  in  1 8  5  4,  in  which  consider- 
able destruction  of  the  cheek  and  contraction  of  the  cicatrix 
had  occurred,  together  with  immobility  of  the  lower  jaw 
and  necrosis  of  a  portion  of  it.  The  bone  having  been 
removed,  it  was  found  that  mobility  was  restored,  and  a 
useful  amount  of  movement  obtained.  Professor  Esmarch 
therefore  suggested,  at  the  Congress  of  Gottingen,  in  1855, 
the  removal  of  a  piece  of  bone  in  cases  of  contracted  cicatrix  ; 
but  did  not  happen  to  meet  with  a  case  suitable  for  the 
operation  until  after  it  had  been  successfully  performed  by 
Dr.  Wilms,  of  Berlin,  in  1858,  soon  after  which  he  himself 
operated  upon  a  case  at  Kiel,  and  with  the  best  results. 
The  operation  was  subsequently  performed  by  Dittel  of 
Vienna,  and  by  Wagner  of  Konigsberg. 

Shortly  after  this  proposal  of  Esmarch,  it  would  appear 
that  Professor  Eizzoli,  of  Bologna,  quite  independently  con- 
ceived a  somewhat  similar  idea,  but  modified  the  proceeding 
by  merely  cutting  through  the  jaw,  without  removing  any 
portion  of  bone.  He  operated  in  this  way  first  in  1857, 
and  subsequently  had  three  other  successful  cases.  In 
Rizzoli's  cases  no  external  incision  appears  to  have  been 
made,  but  the  section  was  accomplislied  from  the  mouth 
with  powerful  forceps.     This  proceeding  has  been  followed 


406  CLOSUKE    OF   THE   JAW. 

by  Professor  Esterle,  from  whose  essay  in  the  Annali 
TIniverscdi  di  Medicina  I  have  extracted,  these  particulars. 

Esmarch's  operation  appears  to  me  to  possess  a  decided 
advantage  over  that  of  Eizzoli,  in  the  fact  that  a  piece  of 
bone  is  removed,  by  which  the  formation  of  a  false  joint  is 
facilitated,  as  we  know  by  experience  in  cases  of  resection 
of  the  elbow,  &c. ;  and  the  external  incision  can  never  be 
a  matter  of  any  importance,  whilst  it  admits  of  the  applica- 
tion of  the  saw,  and  so  avoids  risk  of  splintering  the  bone. 

Mr,  Mitchell  Henry  was,  I  believe,  the  first  surgeon  to 
put  Esmarch's  operation  into  practice  in  this  country,  he 
having  performed  it  a  few  weeks  before  myself.  The 
patient  was  a  female,  on  whom  a  variety  of  operations  had 
been  performed  (among  others,  division  of  the  masseter), 
and  whom  I  had  had  under  my  own  care  at  the  St.  G-eorge's 
and  St.  James's  Dispensary,  two  years  before,  when  I 
divided  the  cicatrices  freely,  and  screwed  the  mouth  open, 
but  without  permanent  benefit.  Mr.  Henry  employed  the 
chain  saw,  and  removed  about  half  an  inch  of  bone.  The 
patient,  unfortunately,  sank  a  few  days  afterwards,  appar- 
ently from  pyaemia  and  exhaustion.  In  my  own  cases  I 
used  an  ordinary  narrow  saw,  in  preference  to  the  chain, 
and  was  enabled  to  remove  sufficient  bone  to  give  free 
movementj  through  a  small  incision  along  the  edge  of  the 
jaw. 

The  subject  of  the  contraction  of  cicatrices  in  the  mouth 
and  their  treatment,  though  it  has  attracted  little  notice 
among  British  authors,  has,  on  the  contrary,  excited  much 
attention  in  Paris,  and  has  furnished  the  topic  of  frequent 
discussions  at  the  Societe  de  Chirurgie.  Since  the  date  of 
the  publication  of  a  paper  upon  the  subject  by  M.  Verneuil 
{Archives  G6n4rales,  i860),  several  operations  have  been 
performed  by  French  surgeons,  but  apparently  with  but 
little  success,  since  in  cases  operated  on  both  by  the  method 
of  Esmarch  and  of  Eizzoli  reunion  of  the  divided  jaw  has 
taken  place. 

Thus,  on  February  4th,  1863,  M.  Boinet  brought  before 
the   Society  a  little  girl   on  whom  he  had  previously  per- 


.EIZZOLl'S    OPERATION.  407 

formed  what  he  terms  Esmarch's  operation  (but  which 
appears  to  have  consisted  in  the  simple  division  of  the  jaw, 
recommended  by  Eizzoli,  and  not  the  removal  of  a  wedge  of 
bone,  as  originally  proposed  by  Esmarch),  and  in  whom  the 
bone  had  reunited.  M.  Deguise  thereupon  quoted  a  case 
in  which  he  had  removed  a  centimetre  and  a  half  of  bone 
with  the  same  unsatisfactory  result,  and  expressed  a  doubt 
whether  a  single  successful  case  could  be  produced.  On 
February  i  ith,  1863,  M.  Deguise  brought  the  case  he  had 
alluded  to  before  the  Society,  and  showed  that  the  failure 
"  depended  upon  the  formation  of  an  osseous  callus  at 
the  level  of  the  resected  portion."  At  the  same  meeting 
M.  Bauchet  showed  a  young  Syrian  girl  in  whom  contrac- 
tion of  the  left  side  had  taken  place,  together  with  a  loss  of 
substance  of  the  cheek  and  commissure  of  the  lips,  equalling 
a  five-franc  piece  in  size.  In  this  case  a  centimetre  and  a 
half  of  the  jaw  was  removed ;  and  though  extensive  suppura- 
tion and  necrosis  of  the  jaw  ensued,  the  girl  made  a  good 
recovery,  and  at  that  date  a  very  satisfactory  amount  of 
movement  and  power  of  mastication  had  been  obtained. 

On  July  29th,  1864,  M.  Verneuil  communicated  to  the 
Societe  de  Chirurgie  the  histories  of  several  cases  operated 
upon  by  M.  Eizzoli  himself,  the  results  of  which  were  most 
satisfactory.  In  the  first,  the  operation  (simple  division  of 
the  jaw  from  within  the  mouth)  was  performed  in  1857, 
and  after  six  years  the  boy  was  able  to  eat  solid  food  most 
satisfactorily ;  the  second  case,  operated  upon  in  the  same 
year,  was  equally  good.  In  the  third  case,  operated  upon 
in  1858,  the  mouth  could  not  be  widely  opened,  and  the 
child  had  some  difficulty  in  speaking.  The  fourth  case 
operated  upon  in  i860,  was  most  satisfactory.  M.  Verneuil 
also  mentioned  a  fatal  case  which  occurred  in  M.  Eizzoli's 
practice,  and  alluded  to  my  paper  in  the  Dublin  Quarterly 
Journal  of  May,  1863. 

It  would  appear  that  M.  Eizzoli  had  adopted  the  plan  of 
inserting  a  foreign  body,  such  as  a  piece  of  gutta-percha, 
between  the  cut  surfaces  of  bone,  with  the  view  of  preventing 
their  reunion,  and  the  possibility  of  doing  this  was  roundly 


408 


CLOSUKE    OF  THE    JAW. 


denied  by  one  of  the  speakers  at  the  Society  de  Chirurgie. 
There  appears  to  me,  however,  to  be  no  difficulty  in  effecting 
this,  provided  the  section  be  made  from  within  the  mouth  and 
without  external  incision,  as  proposed  by  M.  Eizzoli,  but  I 
cannot  speak  with  certainty,  having  no  experience  of  his 
operation. 

One  observation  of  M.  Verneuil's  is,  I  think,  worthy  of 
notice — namely,  that  all  Eizzoli's  successful  cases  have  been 
examples  of  contraction  within  the  mouth  without  loss  of 

Fig.  i8o. 


substance  of  the  cheek,  whereas  the  unsuccessful  cases  of  the 
operation  which  had  occurred  in  Paris  had  suffered  consider- 
able damage  in  the  soft  tissues  ;  and  he  suggests  that  in  these 
cases  Esmarch's  operation  may  be  more  properly  applicable. 
In  one  of  my  cases  the  loss  of  substance  in  the  cheek  had 
been  replaced  by  a  dense  cicatrix,  which  it  would  have  been 
unwise  to  interfere  with  from  within  the  mouth,  and  at  the 
same  time,  owing  to  its  firm  contraction,  it  would  have  been 
impossible  to  have  performed  Eizzoli's  operation  in  the  way 
he  recommends — namely,  without  any  external  incision.  I 
therefore  resorted  to  Esmarch's  proceeding,  with  the  results 
of  which  I  have  every  reason  to  be  satisfied. 


author's  case  of  esmarch's  operation. 


409 


Tlie  first  case  in  which  I  performed  Esmarch's  operation  was 
that  of  a  boy,  aged  fifteen,  who  was  sent  to  me  by  Mr.  Martin, 
of  Portsmouth,  in  1862,  with  complete  closure  of  the  jaws,  the 
result  of  the  contraction  of  cicatrices  within  the  mouth  follow- 
ing extensive  necrosis.  The  cicatrices  had  been  divided,  and 
his  mouth  screwed  open  in  1856,  but  without  permanent 
benefit,  and  he  obtained  his  food  by  rubbing  it  between  his 
teeth,  or  by  putting  it  through  an  aperture  between  the  teeth 

Fig.  181. 


on  the  right  side.  The  mouth  was  firmly  closed,  the  teeth 
overlapping ;  there  was  a  cicatrix  at  tlie  right  angle  of  the 
mouth,  and  a  dense  band  could  be  felt  within  the  mouth  on 
the  same  side.  Fig.  180  shows  his  condition  on  admission.  I 
made  an  incision  two  inches  long  upon  the  lower  border  of 
the  jaw,  in  front  of  the  right  masseter,  and  removed  a  wedge 
of  bone  measuring  rather  more  than  a  quarter  of  an  inch 
along  the  upper,  and  half  an  inch  along  the  lower  border. 
The  piece  contained  the  mental  foramen.  The  mouth  could 
now  be  freely  opened,  and  the  boy  was  discharged  at  the  end 
of  a  month,  able  to  open  his  mouth,  as  seen  in  Fig.  181;  the 
distance  between  the  teeth  being  seven-eighths  of  an  inch. 
The  second  case  in  which  I  operated  in  the  same  manner 


410 


CLOSUEE    OF    THE    JAW. 


was  complicated  by  the  presence  of  a  dense  cicatrix,  occupy- 
ing nearly  the  whole  of  the  cheek  of  the  affected  side.  The 
angle  of  the  mouth  had  also  given  way  during  a  recent  attack 
of  fever,  and  the  patient  presented  the  unsightly  appearance 
shown  in  Fig.  182.  The  patient  was  aged  twenty-three,  and 
the  sloughing  and  contraction  occurred  at  the  age  of  six. 
She  was  sent  to  me  by  Mr.  BuUen,  of  the  Lambeth  Infirmary, 
in  January,  1864.  I  made  an  incision  along  the  border  of 
the  jaw,  and,  as  in  the  former  case,  removed  a  wedge  of  bone 

Fig.  182. 


measuring  seven-eighths  of  an  inch  along  its  lower  border. 
This  also  contained  the  mental  foramen.  The  patient's  mouth 
could  now  be  opened  to  the  extent  of  half  an  inch.  I  made 
two  subsequent  attempts  to  remove  the  deformity  of  the 
cheek  by  plastic  operations,  but  only  succeeded  in  restoring 
the  commissure  of  the  lips,  the  vitality  of  the  cicatricial  tissue 
being  too  low  to  admit  of  its  uniting  with  other  tissues.  At 
the  time  of  her  discharge  the  commissure  of  the  lip  was 
half  an  inch  in  breadth ;  and  with  a  piece  of  plaster  over 
the  opening  which  was  left  behind  it,  the  patient  was  very 
comfortable.  Fig.  183  shows  her  condition  at  this  time 
with  the  mouth  open. 


EESULTS    OF    ESMAECH  S    OPEEATION. 


411 


With  regard  to  the  permanence  of  the  relief  afforded  in 
these  cases,  I  may  mention  that  B.  B.,  the  boy  on  whom  I 
operated  in  July,  1862,  continues  in  perfect  health,  and  is 
able  to  take  plenty  of  nourishment,  although  the  movements 
of  the  jaw  have  very  decidedly  diminished,  owing,  apparently, 
to  contraction  of  the  fibrous  tissues  around  the  new  joint,  due, 
as  the  patient  and  his  mother  believe,  in  the  first  instance,  to 
the  cold  of  the  severe  winter  following  the  operation,  from 
which  he  suffered  considerably. 

Fig.  183. 


In  March,  1865,  I  had  the  boy  up  from  the  country,  and 
found  that  the  space  between  the  left  molar  teeth  had  dimin- 
ished from  seven-eighths  to  one-eighth  of  an  inch,  and  that 
between  the  left  lateral  incisors,  from  five-eighths  to  a  quarter 
of  an  inch.  The  movement  was  still  free  enough  to  show 
that  osseous  ankylosis  had  not  taken  place  in  the  new  joint ; 
but  whether  the  contraction  was  due  simply  to  changes  at  that 
point  or  to  the  contraction  of  some  band  it  was  impossible  to 
determine,  as  the  boy  positively  refused  all  interference, 
either  with  or  without  chloroform.  In  this  case,  however,  I 
believe  that  I  was  not  sufficiently  careful  to  make  the  section 
of  the  bone  entirely  in  front  of  the  cicatrices,  a  point  I  bore  in 
mind  in  the  second  operation.     He  was  alive  in  1893. 


412  CLOSUKE    OF    THE   JAW. 

The  second  patient,  E.  J.,  is  in  perfect  health,  and  has 
good  use  of  her  jaw.  I  saw  her  in  December,  1893,  i^ 
good  health,  and  with  perfect  movement  of  the  joint.  The 
opening  in  the  cheek  remained  the  same. 

In  1883,  I  again  performed  the  operation  in  University 
College  Hospital,  on  a  woman,  aged  thirty-two,  who  was 
kicked  by  a  horse  on  the  right  side  of  the  face,  when  eleven 
years  of  age,  since  which  she  had  had  more  or  less  closure  of 
the  jaws.  The  teeth  were  firmly  closed,  the  lower  incisors 
being  forced  outwards.  It  was  clearly  a  case  of  ankylosis  of 
the  temporo-maxillary  articulation,  and  I  should  have  pre- 
ferred to  operate  in  that  region  but  for  the  patient's  anxiety 
to  be  relieved  as  soon  as  possible,  in  order  to  return  to 
her  family.      She  recovered,  with  good  use  of  the  jaw. 

In  connection  with  this  subject,  and  to  show  the  patho- 
logical result  of  the  proceeding,  I  may  refer  to  the  following 
account  of  the  post-mortem  examination  of  a  case  of 
Esmarch's  operation,  read  before  the  Societe  Imperiale  de 
Chirurgie,  September  5th,  1866.  M.  Boinet  showed  the 
lower  jaw  of  a  girl  who  had  closure  of  the  jaws,  from 
cicatrices  resulting  from  cancrum  oris.  Eizzoli's  operation 
had  been  performed  at  the  beginning  of  i860,  but  failed  at 
the  end  of  twelve  months.  In  1863  a  wedge  was  removed 
with  perfect  success.     She  died  of  phthisis  in  1866. 

"  The  right  ramus  of  the  jaw  is  deformed,  being  shorter 
and  broader  than  on  the  opposite  side.  The  condyle  and 
the  coronoid  process  are  less  separated  and  shorter  than  on 
the  left  side,  and  the  sigmoid  notch  is  shallower.  The  left 
temporo-maxillary  articulation  has  lost  much  of  its  mobility, 
and  the  ligaments  are  shortened.  The  sections  had  been 
made  in  the  middle  of  the  body  of  the  bone,  the  angle  being 
intact.  The  lower  border  of  the  jaw  presents  a  difference  in 
length  of  one  centimetre  and  a  half  between  the  two  sides, 
which  corresponds  to  the  breadth  of  the  wedge  of  bone 
removed  at  the  operation.  The  osseous  tissue  of  the 
ascending  ramus  appeared  reddened ;  the  dental  nerve  was 
natural  at  its  entry  into  the  inferior  dental  foramen.  Be- 
tween   the    two    portions   of   the  jaw  there  exists   a  very 


CLOSURE    FKOM   A   BONY  BRIDGE.  413 

complete  false  joint,  which  is  permanent  three  years  after 
the  operation ;  it  is  very  mobile,  and  the  parts  which  serve 
as  the  hinge  are  fibrous  and  stretched  so  that  the  middle 
portion  of  the  jaw  can  fall ;  during  life  this  was  sufficient  to 
allow  easily  the  introduction  of  the  forefinger  into  the 
mouth.  The  fibrous  tissue  which  unites  the  bones  occupies 
the  whole  interval  between  the  bones,  and  extends  for 
the  whole  depth  of  the  jaw.  Its  breadth  appears  to  be 
quite  half  a  centimetre,  and  its  strength  uniform," — Gazette 
HebdomadaiTc,  October  12th,  1866. 

The  occurrence  of  an  osseous  lamella  or  bridge  between 
the  two  jaws  is  a  rare  but  not  unique  occurrence.  In  the 
Medical  Gazette  of  July  4th,  1845,  Mr.  J.  G-.  French  has 
reported  and  figured  an  excellent  example  of  ankylosis  pro- 
duced by  a  bridge  of  bone,  which  occurred  under  his  care  at 
the  St.  James's  Infirmary. 

The  patient  was  aged  twenty  two  at  the  time  of  his  death, 
and  the  closure  of  the  jaws  dated  from  infancy.  He  was  fed 
through  an  aperture  made  by  the  removal  of  the  incisors  on 
the  left  side.  At  the  age  of  fourteen,  an  operation  for  his 
benefit  had  been  undertaken  by  an  eminent  surgeon,  and  in- 
cisions in  the  mouth  had  been  made  with  this  object,  but  with- 
out any  good  result.  On  post-mortem  examination,  the  jaws 
were  perfectly  united  on  the  left  side,  and  only  the  smallest 
degree  of  motion  was  possible  on  the  right ;  the  soft  parts 
were  removed  and  the  base  of  the  skull  was  macerated,  when 
ankylosis  was  discovered  to  exist  between  the  upper  and 
lower  jaws  on  the  left  side,  the  ramus  of  the  inferior  maxilla, 
immediately  internal  to  the  mental  foramen,  extending 
upwards  by  a  broad  thin  plate,  and  uniting  with  a  corre- 
sponding plate  of  the  superior  maxilla,  a  cartilaginous  material 
forming  the  bond  of  union.  The  articulation  of  the  jaw  was 
normal. 

Mr.  Trueman  also  mentioned  in  the  discussion  which 
followed  the  narration  of  Mr.  Cartwright's  case  {British 
Journal  of  Dental  Science,  June,  1864)  that  he  remembered 
seeing  in  the  Museum  at  Berlin  a  very  curious  case  where 
cicatrices  existed  on  both  sides  of  the  mouth,  which  were 


'414  CLOSUEE   OF    THE    JAW. 

completely  ossified,  so  that  the  preparation  showed  the  two 
jaws  united  by  filaments  of  bone,  on  either  side  of  the  jaw 
externally. 

Having  thus  shown  that  closure  of  the  jaws  depends  upon 
various  causes,  and  is  amenable  to  various  methods  of  treat- 
ment, of  which  I  have  had  personal  experience,  I  think  I 
may  venture  to  contrast  these  methods. 

In  cases  of  cicatrix,  I  give  the  preference  to  Esmarch's 
method  of  removing  a  wedge  from  the  lower  jaw  on  one  or 
both  sides.  The  operation  is  a  comparatively  easy  one,  and 
in  cases  where  only  one  side  of  the  jaw  is  affected,  restores 
the  patient  a  very  useful  though  one-sided  amount  of  masti- 
catory power  in  two  or  three  weeks,  and  with  very  little 
suffering  or  annoyance. 

In  cases  of  fibrous  ankylosis  of  the  temporo-maxillary  joint 
it  may  be  worth  while  to  try  division  of  the  adhesions,  and 
failing  that  to  resect  the  condyle. 

In  cases  of  bony  ankylosis  of  the  joint,  division  of  the 
ramus  of  the  jaw  beneath  the  masseter  though  satisfactory 
at  first  has  disappointed  me  in  its  permanent  results,  and  I 
have  no  experience  of  Dr.  Mears'  very  severe  operation  of 
removing  the  bone  through  the  mouth.  Chiselling  out  the 
bone  representing  the  condyle  is  a  difficult  and  somewhat 
dangerous  proceeding  as  regards  the  facial  nerve,  and  I 
should  prefer  to  remove  one  or  both  angles  of  the  jaw  by 
Esmarch's  method. 


CHAPTEK    XXV. 

DEFORMITIES    OF    THE   JAWS. 

The  scope  of  this  work  does  not  embrace  those  congenital 
deformities  of  the  gum  and  palate  which  are  familiar  to  the 
surgeon  in  combination  with  hare-lip,  but  there  are  certain 
examples  of  deformity,  the  result  of  disease,  which  may  be 
conveniently  grouped  together  here. 

In  describing  the  tumours  of  the  jaw,  mention  has  been 
made  and  drawings  given  of  cases  of  deformity  the  result 
of  pressure  upon  the  opposite  jaw  of  some  growth  of  large 
size ;  thus,  at  page  321  will  be  found  an  instance  of 
deformity  of  the  upper  jaw,  due  to  the  pressure  of  a  large 
fibrous  tumour  of  the  lower  jaw;  and  at  page  273  an 
example  of  deformity  of  the  lower  jaw,  due  to  the  pressure 
of  a  large  osseous  tumour  of  the  superior  maxilla. 
Tumours  within  the  mouth,  unconnected  with  the  jaws, 
may,  however,  induce  deformity  mechanically,  hypertrophy 
of  the  tongue  being  the  disease  most  frequently  met  with, 
of  which  several  instances  will  be  found  in  vol.  xxxvi  of 
the  Meclico-Chirurgical  Tmnsactions,  in  papers  upon  that 
disease,  by  Dr.  Humphry,  of  Cambridge,  and  Mr.  Joseph 
Hodgson.  Dr.  Humphry's  patient  was  a  girl  of  eleven 
years,  who  had  had  a  much  hypertrophied  and  prolapsed 
tongue  for  eight  years.  "  Owing  to  the  constant  pressure 
of  the  tongue  on  the  mental  portion  of  the  lower  jaw  a 
curvature  had  taken  place  in  that  bone,  just  in  front  of  the 
masseter  muscles,  in  such  a  manner  that  a  wide  interval 
always  existed  between  the  incisors  and  bicuspids  of  the 
two  jaws.  Even  when  the  mouth  was  closed — that  is  to 
say,  when  the  corresponding  molar  teeth  were  in  contact — 


416  DEFOEMITIES    OF   THE    JAWS. 

this  interval  between  the  incisors  measured  nearly  two 
inches,  being  increased  by  the  horizontal  direction  which 
the  inferior  incisors  and  the  alveolar  process  of  the  lower 
jaw  had  assumed.  These  were  so  placed  as  to  form  a  wide 
channel  in  which  the  tongue  rested.  Moreover,  the  teeth, 
especially  the  two  central  incisors,  were  further  apart  than 
natural,  and  encrusted  with  tartar,  which  in  some  measure 
filled  up  the  spaces  between  them,  and  prevented  their 
sharp  edges  from  injuriously  pressing  upon  the  tongue." 
The  deformity,  therefore,  closely  resembled  that  seen  in 
Fig.  184,  which  was  due,  however,  to  external  causes.  Dr. 
Humphry  removed  the  anterior  part  of  the  tongue  success- 
fully, and  then  endeavoured  to  remedy  the  deformity  of 
the  jaw  by  fitting  a  cap  of  calico  and  metal  to  the  head, 
with  a  hooked  bar  of  iron  projecting  from  it  like  a  horn 
over  the  forehead.  The  bar  was  attached  to  the  hinder 
part  of  the  framework  of  the  cap  by  a  hinge,  and  to  the 
forepart  by  a  screw,  which  enabled  the  surgeon  to  alter 
its  elevation  according  to  circumstances.  A  thick  belt 
of  india-rubber  passed  from  the  hook  beneath  the  chin, 
and  exerted  considerable  pressure  upon  it.  The  apparatus 
was  worn  for  several  hours  at  a  time.  When  its  use  was 
commenced  on  January  1 8th,  four  months  after  the  operation 
on  the  tongue,  the  interval  between  the  maxillary  alveoli 
was  If  inch,  having  decreased  about  a  quarter  of  an  inch. 
On  February  22nd  it  was  li  inch,  and  in  August  ^  of  an 
inch.  After  this  the  change  took  place  very  slowly,  though 
the  deformity  was  at  length  almost  removed. 

A  very  similar  condition  of  the  lower  jaw,  but  in  an 
earlier  stage,  existed  in  a  child,  aged  three,  from  whom  Sir 
J.  Paget  successfully  removed  the  hypertrophied  portion  of 
the  tongue,  in  February,  1864.    (Lancet,  Apvil  i6th,  1864.) 

Mr.  Oliver  Chalk  has  also  narrated,  in  the  Pathological 
Society's  Transactions,  vol.  viii,  a  case  of  deformity  of  the  jaw 
dependent  upon  enlargement  of  the  tongue  in  which  he  con- 
sidered that  a  partial  dislocation  of  the  jaw  was  produced, 
and  where  benefit  was  derived  from  the  use  of  an  elastic 
support. 


DEFOUMITIES    OF    THE    JAWS. 


417 


TJie  intiueuce  of  the  habit  of  sucking  the  thumb  upon 
the  position  of  the  front  teetli  is  generally  acknowledged, 
and  the  practice,  if  persisted  in,  may  produce  very  consider- 
able deformity  of  the  jaws.  Some  drawings  illustrating  a 
paper  on  this  subject,  by  Mr.  Vasey,  in  the  Pathulugical 
Society's  Transactions,  vol.  vi,  show  the  resulting  deformity  ex- 
tremely well.  Dr.  Thomas  Ballard  has  also  called  attention 
to  the  deformity  resulting  from  the  habit  of  '  tongue- 
sucking,'  to  which  he  attributes  many  of  the  ailments  of 
children. 

The  influence  of  cicatrices  outside  the  mouth  in  producing 
deformity  of  the  jaw  hj  their  contraction  in  early  life  is 

Fig.  184. 


well  ascertained,  and  every  surgeon  must  have  met  with 
painful  examples  of  the  kind.  Fig.  184,  from  Mr.  Tomes' 
work,  shows  the  condition  of  the  lower  jaw  in  a  young 
woman  twenty-two  years  of  age,  her  chin  having  been 
drawn  down  towards  the  sternum  by  a  broad  cicatrix,  conse- 
quent upon  a  burn  received  when  five  years  old. 

In  all  these  cases  the  deformity  partakes  of  the  same 
character,  and  if  seen  early  enough  is  to  some  extent  amen- 
able to  treatment.  The  slighter  cases  depending  upon 
thumb-sucking  are  usually  treated  by  the  dental  surgeon, 
who  in  rectifying  the  position  of  the  teeth  necessarily  im- 
proves the  condition  of  the  jaw.  In  the  more  severe  cases, 
constant  support  by  an  elastic  band  making  traction  upon 
the  jaw  will  be  of  much  service,  as  in  the  cases  of  Dr. 
Humphry  and  Mr.  Chalk.     The  cases  depending  upon  the 


•2  D 


418  DEFORMITIES    OF    THE    JAWS. 

contraction  of  cicatrices  can  only  be  relieved  by  treating  the 
cicatrices,  and  the  pressure  of  a  screw-collar,  worn  for  the 
purpose  of  extending  these,  will  do  much  to  restore  the  shape 
of  the  jaw,  if  the  case  is  not  one  of  too  long  standing. 

Disease  originating  within,  the  mouth  may  lead  to  ulti- 
mate deformity  of  the  jaws  ;  thus,  cancnim  oris,  in  addition 
to  leading  to  closure  of  the  jaws,  as  described  in  a  pre- 
vious chapter,  may  lead  to  very  considerable  deformity  of 

Fig.  185. 


the  alveoli.  Mr,  Bernard,  of  Clifton,  successfully  treated, 
by  Esmarch's  operation,  a  case  of  closure  with  deformity 
thus  caused  ;  but  a  still  more  remarkable  case  was  under 
the  care  of  my  friend,  the  late  Mr.  W.  Harrison,  to 
whom  I  am  indebted  for  the  accompanying  engravings 
of  it.  The  patient,  aged  thirty-six,  had  suffered  in 
childhood  from  cancrum  oris,  which  had  destroyed  the 
greater  part  of  the  right  cheek.  His  appearance  is  shown 
in  Fig.  185,  and  it  will  be  seen  that  the  lips  were  widely 
separated,  and  that  a  considerable  protrusion  of  the  alveolar 
processes  of  both  jaws,  with  their  teeth,  had  taken  place 
between  them.     Behind  this  point   the  jaws  were  united 


DEFORMITIES    OF   THE    JAWS,  419 

by  a  bridge  of  bone,  and  the  patient,  who  was  totally  unable 
to  open  his  mouth,  fed  himself  through  an  aperture  between 
the  teeth  on  the  left  side.  In  October,  1867,  Mr.  Harrison 
extracted  the  seven  teeth  which  projected,  and  reflected  the 
gums  from  the  adjacent  alveoli,  when  as  much  of  them  as 
was  thought  desirable  was  removed  with  the  bone-forceps. 
The  molar  teeth,  which  had  been  driven  into  the  interior 
of  the  mouth,  were   then   extracted    with    some   difficulty, 

Fig. 1S6. 


when  a  pillar  of  bone,  about  the  size  of  an  ordinary  lead- 
pencil,  connecting  the  alveoli,  was  brought  into  view,  but 
was  not  interfered  with.  The  gums  were  brought  together 
with  stitches,  and  the  operation  was  concluded.  The  ap- 
pearance of  the  patient  some  weeks  afterwards  is  shown  in 
Mg.  1 86. 

The  patient  having  been  transferred  to  the  care  of  Mr. 
James  Lane,  that  gentleman  proceeded  to  perform  a  plastic 
operation  for  the  improvement  of  the  condition  of  the  lips. 
A  very  long  V-shaped  incision  was  made,  extending  from 
the  extremities  of  the  lips  (which  were  firmly  attached  to 
the  alveoli)  to  a  point  about  an  inch  in  front  of  the  ear, 
thus  embracing  within  it  the  cicatrix  of  the  original  disease, 


420 


DEFOEMITIES    OF    THE    JAWS. 


The  tissues  were  freely  dissected  from  the  upper  and  lower 
jaws,  and  were  brought  together  over  the  old  cicatrix.  An 
incision,  two  inches  long,  was  made  along  the  lower  border 
of  the  jaw,  to  enable  this  to  be  done  without  too  great 
tension,    and    the  parts   were  held  together  with   hare-lip 

Fig.  187. 


^^.,. 


pins  and  sutures.  The  operation  was  perfectly  successful, 
and  the  subsequent  appearance  of  the  patient  is  shown  in 
Kg.  187. 

The  interesting  details  of  this  case  will  be  found  in  a 
paper  read  by  Mr.  Harrison,  before  the  Odontological 
Society,  in  May,  1868  (British  Journal  of  Dental  Science, 
May,  1868). 


INDEX. 


Abscess,  alveolar       .... 
„         after  fracture 
,,  in  substance  of  jaw 

„  of  antrum     .... 

Actinomycosis  of  the  jaws  . 

Adams,  Mr.  W. ,  on  cysts  of  antrum 
„       Dr.  R.,  on  cysts  of  lower  jaw 

Adenoma  of  palate       .... 

Alveolar  abscess 

Alveolus,  fracture  of    . 

,,        difiEused  periostitis  of    . 

„        localised  chronic  periostitis  of 

Amaurosis  from  diseased  antrum 

Angle,  Dr.,  treatment  of  fractured  jaw 

Angioma  of  palate        .... 

Ankylosis  of  temporo-maxillary  joint  . 

Antrum,  diseases  of 

suppuration  in 
dropsy  of 
cysts  of 
polypus  of 
falling  in  of  . 
epithelioma  of 

Articulation,  temporo-maxillary,  diseases  of 

Author's  case  of  fractured  alveolus 
,,  .,        necrosis  of  lower  jaw 

„  „        hyperostosis  of  jaw    . 

„  „        dentigerous  cyst 

„  „        cystic  sarcoma  of  lower  jaw 

„  „        multilocular  cystic  tumour 

„  „        odontoma . 

„  „         hypertrophy  of  gums 

„  „        epulis 

„  „        tumour  of  palate 

„  „        epithelioma  of  antrum 

.,  gums 

„  „         fibroma  of  upper  jaw 

„  „         enchondroma  of  upper  jaw 

„  „        osteoma  ,,  „ 

„        round- cell  sarcoma  of  upper  jaw 
„  „        epithelioma  ,,  ,, 

„  ,,        recurrent  sarcoma    „  ,, 

,,  „        ivory  exostosis  of  lower  jaw 


II, 


PAGE 
92 

14 
98 

160 

92 

43 

89 

99 

149 

35 
250 

395 
141 

H5 
157 
159 
162 

165 
166 

375 
II 

105,  119 

136 

189 

200,  206 

202,  203 

.     218 

.     228 

238,  239 

252,  253 

167,  302 

.     246 

.     264 

.     266 

.     272 

.     296 

299,  301 

•  314 

•  327 
2  E 


422 


INDEX. 


Author's  case  of  myeloid  of  both  sides  of  lower  jaw   . 
„  „        round-celled  sarcoma        ,,        ,, 

,,  ,,        chondro-sarcoma  ,,        „ 

„  ,,        ossifying  sarcoma  „        „ 

„  ,,        epithelioma  of  lower  jaw  . 

of  chin    .         .         .         . 
„  „  „  of  gland  adherent  to  jaw 

„  „         Esmarch's  operation  for  closure 

„  ,,         closure  of  jaws  treated  with  shields 

„  ,,         disease  of  temporo-maxillary  joint     . 

„  „        hypertrophy  of  neck  of  condyle 


•  332 

•  334 

•  342 

•  346 
351,  354 

•  356 
.  358 

•  405 
.  402 

•  377 
.  382 


Bean's  interdental  splint 38 

Beaumont,  Mr.,  enchondroma  of  lower  jaw 322 

Boinet,  M.,  post-mortem  examination  after  Esmarch's  operation        .  412 

Broca,  M. ,  on  fibrous  odontomata        .......  264 

Bryant,  Mr.,  necrosis  of  inter-maxillary  bones 113 

Butcher,  Mr.,  on  cysts  of  lower  jaw 207 

,,          ,,          vascular  tumovir  of  upper  jaw  .....  288 


Caecinoma  of  palate  . 

„  of  upper  jaw     . 

„  of  lower  jaw 

Cannon-ball,  injury  to  jaws  by 
Canton,  Mr. ,  myeloid  tumour  of  upper  jaw 
Cap  for  fractured  jaw  . 
Cartilaginous  tumours  of  upper  jaw 
„  0  lower  jaw 

Cattlin,  Mr. ,  on  the  antrum 
Chalk,  Mr.  O.,  deformity  of  jaw 

,,  ,,        reproduction  of  teeth 

Chin,  silver 

Chondro-sarcoma  of  upper  jaw    . 

,,  „  lower  jaw    . 

Closure  of  the  jaw 

Coates,  Mr. ,  myeloid  tumour  of  upper  jaw 
Collis,  Mr.,  enchondroma  of  upper  jaw 
Complications  of  fractured  jaw   . 
Condyle,  fractured  neck  of  . 
Couper,  Mr.,  case  of  old  dislocation     . 
Craven,  Mr.,  medullary  sarcoma  of  upper  jaw 

„        „    myeloid  sarcoma  of  lower  jaw. 
Cystic  sarcoma     . 
Cysts  of  antrum  . 

„     of  teeth 

„    dentigerous 

„    multilocular,  of  lower  jaw 


254 
299 
350 
64 
282 

37 
265 

323 
141 
416 
123 

63 
292 

342 
389 
286 
271 
9 

6,  n 

80 

29s 

331 

200 

159 
174 
180 
192 


Debout  on  gunshot  injuries 
Deformities  of  the  jaws 
Dental  cysts         .... 
Dentigerous  cysts 
Dentinal  tumours  (see  Odontomata) 
Diabetic  alveolar  periostitis 
Diagnosis  of  tumours  of  upper  jaw 
„  ,,  lower  jaw 


61 

415 
174 
180 

90 

303 
360 


INDEX. 

Dislocation  of  teeth     .... 
with  fracture     . 
of  lower  jaw 

pathology  of 
symptoms  of 
old-standing 
rare  forms     . 
congenital 
treatment  of 

Dropsy  of  antrum         .... 

Duka,  Dr.,  case  of  ivory  tumour  of  upper  jaw 


423 

PACK 
lO 

i6 
72 
73 

n 
80 
82 
83 
84 
157 
277 


Enchondroma  of  upper  jaw 
, ,  lower  jaw 

Epithelioma  of  gums    . 
„        of  antrum 
Epulis  .         .         .         .         • 

„      myeloid     . 

„       epitheliomatous 

„      treatment  of     .         . 
Esmarch,  Professor,  on  closure  of  jaw 
Eve,  on  pathology  of  multilocular  cysts 
Extraction  of  teeth  causing  fracture   . 


265 

323 
24"; 
166 

234 
236 

245 
242 

405 


Falling  in  of  antrum         ... 
False  joint  after  fracture     ... 
Fearn,  Mr. ,  dentigerous  cyst 
Fergusson,  Sir  W.,  case  of  hyperostosis  _ 
„  case  of  hydrops  antri 

,,  cysts  in  lower  jaw 

„  odontoma 

„  ivory  tumour  of  upper  j 

„  spindle-celled  sarcoma  of  upper  jaw 

„  fibrous  tumour  of  lower  jaw 

Fibroma  of  upper  jaw  . 
„  lower  jaw  . 

Forceps,  Fergusson' s    . 
,,        Liston's 
„        Stromeyer's   . 
Forget,  Dr. ,  on  dentigerous  cysts 

„  on  odontomata 

Four-tailed  bandage     . 
Fracture  of  lower  jaw  . 

„  „  position  of 

„  ,,  symptoms  of 

,,  „  complications  of 

„  ,,  treatment  of 

„        neck  of  condyle  of  lower 

„         ramus  of  lower  jaw   . 

„        coronoid  process 

„        teeth 

„        alveolus     . 

„        glenoid  cavity   . 

„  ,,  with  dislocation 

„    upper  jaw .... 

„       „    complications  of 


16S 
23 
I8S 
134 
159 
202 

215 
274 
291 
320 
258 
316 
244 
243 

86 
186 
210 

26 


4 

9 

26 

6 


TO 
II 

13 
16 

43 


424 


INDEX. 


PAGE 

Gensoul,  on  removal  of  upper  jaw 305 

Giraldes,  M.,  on  cysts  of  antrum 

160 

Goodwillie,  Dr.,  on  temporo-maxillary  disease 

386,  392 

Graefe's  apparatus  for  fractured  upper  jaw- 

•       51 

Gross,  Dr.,  on  closure  of  jaw 

.     400 

Growths  within  antrum 

.     166 

Gnms,  diseases  of         ...         . 

.     226 

„      hypertrophy  of  . 

.     226 

,,      polypus  of          .... 

•     231 

„      papilloma  of      ...         . 

•     233 

„      epithelioma  of  . 

•     245 

Gunning's  interdental  splints 

33 

Gunshot  injuries  of  jaws 

53 

Gutta-percha  wedges  for  fracture 

28 

„            splint      .... 

53 

Guerin,  Dr.  A-,  investigations  of  fracture  of  upper  jaw 

47 

H.a;MOEEHAGE  after  fracture .  9,  "J.! 

Hamilton's  sling  for  fracture 

27 

Hamanond's  wire  s^Dlint 

28 

Harrison,  Mr.,  odontoma     . 

217 

„             deformity  of  jaws 

418 

Hart,  Mr.,  necrosis  of  upper  jaw 

117 

Hay  ward,  Mr.,  cap  for  teeth 

37 

Hepburn,  Mr. ,  case  of  angular  union 

15 

Hill,  Mr.  B.,  modification  of  Lonsdale's  splint     . 

39 

Hilton,  Mr.,  ivory  tumour  of  upper  jaw       .... 

274 

Holt,  Mr.,  recurrent  fibroid  of  lower  jaw     .... 

339 

,,          closure  of  jaws 

403 

Humphry,  Dr.,  prolapse  of  tongue,  producing  deformity  of  jaw 

41s 

Hydrops  antri      ......... 

157 

Hyperostosis 

130 

Hypertrophy  of  gums 

226 

„                neck  and  condyle 

379 

Inflammatory  diseases  of  the  jaws 89 

Interdental  splint  (Gunning's)     . 

33 

„          „          (Bean's)  . 

38 

Irregular  union  after  fracture 

18 

Ivory  tumour  of  upper  jaw  . 

274 

„          ,,          lower  jaw 326 

Jaws,  gunshot  injuries  of 53 

inflammation  of 

.       88 

„       abscess  of. 

92,98 

„       periostitis  of     . 

88,  89 

„       necrosis  of  ■      . 

103 

„               ,,            syphilitic 

I  OS 

„              „           mercurial 

107 

„              ,,           phosphorus 

109 

„              ,,           exanthematous 

113 

„       deformities  of    . 

415 

Jaw,  upper,  fracture  of        .         .         . 

43 

„                ,,             treatment  of    . 

49 

„            tumours  of         .         .         . 

257 

„                ,,              fibrous 

258 

INDEX. 

Jaw,  upper,  tumours  of,  cartilaginous 

„  „  osseous  . 

„  „  myeloid  sarcoma   . 

„  ,,  vascular  sarcoma  . 

„  „  spindle-celled  sarcoma 

„  ,,  chondro-sarcoma  . 

„  ,,  ossifying  sarcoma  . 

„  „  round-celled  sarcoma 

„  „  epithelioma 

„  ,,  diagnosis  of 

„  ,,  prognosis  of 

operations  on     . 
Jaw,  lower,  fractures  of 

„  ,,  complications  of 

„  „  treatment  of 

„  „  suture  of 

„  dislocation  of  . 

„  cysts  of     . 

„  tumours  of 

„  „  fibrous 

„  ,,  cartilaginous 

„  „  osseous     . 

,,  „  myeloid  sarcoma 

„  „  round-celled  sarcoma 

„  „  spindle-celled  sarcoma 

„  „  chondro-sarcoma 

.,  „  ossifying  sarcoma 

„  „  epithelioma 

„  ,,  diagnosis  of 

„  operations  on    . 


425 

PAOK 
265 
272 
281 
286 
290 
291 
292 

293 
299 

304 

304 
I 

9 

26 

40 

72 

170 

316 

316 

323 

325 

330 

334.  342 

336 

342 

346 

350 

360 

361 


KiNLOCH,  Dr.,  wiring  of  fragments 


40 


Lawson,  Mr. ,  recurrent  fibroid  of  lower  jaw 

,,  „  chondroma  of  lower  jaw 

Ligature  of  teeth 
Listen,  Mr. ,  case  of  large  epulis  . 

,,  fibrous  tumours  of  upper  jaw 

Lonsdale's  splint 
Lower  jaw,  fracture  of 

„  dislocation  of    . 

,,  tumours  of  (see  Tumours) 


341 
324 
40 
240 
260 

39 
I 

72 


MacGilliveay,  Mr.,  hypertrophy  of  gum 
Maisonneuve  on  dislocation  ... 

Margetson,  Mr.,  case  of  fracture  and  dislocation 
Multilocular  cysts  of  lower  jaw   . 

„  cystic  tumour 

Mycosis  aspergillina  of  the  antrum 
Myeloid  epulis      .... 

„       sarcoma  of  upper  jaw     . 

,,  ,,  lower  jaw    . 


of  tooth 


228 

75 

II 

192 

200 

373 
236 
281 
330 


Neck  of  condyle  fractured 
Necrosis  of  jaws  . 


6 

103 


426 


INDEX. 


Necrosis  of  alveolus 104 

exanthematous 113 

syphilitic 105 

mercurial      .         .         . 107 

phosphorus-  ..........     109 

following  injuries  .         .         .         .         .         .         .         .116 

symptoms  of  .         .         .         .         .         .         .         .         .111 

repair  after   .         .         .         .         .         .         .         .         .         .118 

treatment  of .     125 


after  fracture        .... 
,,  of  symphysis    . 

Nelaton,  on  dislocation  .... 
Neuralgia  after  fracture  .... 
Newland-Pedley,  Mr.,  case  of  fractured  jaw 
Non-union  of  fracture  .... 


72, 
II, 


Odontomata 210 

Old- standing  dislocations 80 

Operations  on  upper  jaw      .........  304 

„              lower  jaw      .........  361 

Ossifying  sarcoma 292,  346 

Osteoma  of  upper  jaw 272 

„          lower  jaw          .........  325 


Paget,  Sir  J.,  polypus  of  antrum        .         .         .         .         .         .         .  163 

,,        Stephen,  tumours  of  palate     .         .         .         .         ...         .  249 

Palate,  tumours  of  the         .         .         .         .         .         .         .         .         .  249 

Paralysis  of  dental  nerve ii>  49 

Parasitic  diseases  of  the  jaws 370 

Periostitis 89,  92 

„        diffused  alveolar 89 

„        localised  alveolar          ........  92 

„               „        chronic  alveolar 99 

,,        tubercular    .         .         .         .         .         .         .         .         .         .  loi 

Permanent  closure  of  jaws 

Phosphorus-necrosis    ..........  109 

Polypus  of  antrum 162 

Ramus  of  lower  jaw  fractured 3 

Repair  after  necrosis    .         .         .         .         .         .         .         .         •         .118 

Rheumatoid  arthritis,  temporo-maxillary 377 

Rigg's  disease       ...........       90 

Rizzoli,"on  closure  of  jaws   .........     405 


Salivary  fistula  after  fracture  .... 

16 

Salter,  Mr.,  case  of  fractured  upper  jaw 

4.3 

„          on  exanthematous  necrosis 

11,3 

,,          on  dentigerous  cysts 

i«3 

„          on  odontomata          .... 

212 

„           on  hypertrophy  of  gum 

226 

„           on  papilloma  of  gum 

233 

Sarcoma  of  palate 

252 

„          upper  ]aw 

281 

,,          lower  jaw 

330 

Savory,  Sir  W. ,  on  re]pair  after  phosphorus-necrosis 

120 

INDEX. 


42V 


Smith,  Mr.  Cox,  case  of  injury  to  symphysi 

„        Prof.  R.  W.,  on  dislocation 
Spasmodic  closure  of  jaw     . 
Splint,  interdental  (Gunning's)     . 

,,  „  (Hammond's  wire) 

„  „  (Bean's)  . 

,,      Lonsdale's,  Hill's  modification  of 

,,       for  lower  jaw    .... 
Sti'omeyer's  dislocation-forceps   . 
Sub-luxation  of  temporo-maxillary  joint 
Sub-periosteal  resection 
Suppuration  in  antrum 
Sutton  on  odontomata 
Suture  of  lower  jaw      .... 
Syme,  Mr.,  osteo-sarcoma  of  lower  jaw 
Symphysis,  necrosis  of  .         .         . 

Symptoms  of  fractured  jaw 
Syphilitic  necrosis       .... 

Tay,  Mr.  W. ,  necrosis  of  lower  jaw     . 

Teeth,  fracture  of         ...         . 
„      dislocation  of    . 
„      ligature  of         ...         . 
,,      tumours  connected  with  . 
„      irregularities  of         .         .         . 

Temporo-maxillary  articulation,  diseases  of 

Thomas's  wire-suture  .... 

Tomes,  Mr.,  on  hypertrophy  of  gums  . 
„         „         dentigerous  cysts 
„        ,,         odontomata . 

Treatment  of  fractures  of  lower  jaw    . 
,,  upper  jaw    . 

Tumours  connected  with  teeth     . 
,,        papillary,  of  gum  . 
,,        of  palate        .... 
,,        of  upper  jaw 
,,  „  fibrous 

,,  „  cartilaginous     . 

„  „  osseous 

„  ,,  myeloid  sarcoma 

,,  ,,  vascular  sarcoma 

,,  „  spindle-celled  sarcoma 

„  „  chondro-sarcoma 

„  ,,  round-celled  sarcoma 

„  „  carcinomatous 

„  „  diagnosis  of 

,,  „  treatment  of 

Tumours  of  lower  jaw  . 

„  „  fibrous 

„  ,,  cartilaginous 

,,  ,,  osseous 

„  ,,  myeloid  sarcoma 

„  „  spindle-celled  sarcoma 

„  „  mahgnant  . 

,,       ,,     diagnosis  of 

,,       ,,     treatment  of 

Union  of  fracture  after  necrosis 

,,   irregular,  of  fractured  lower  jaw 


22 

78 

33 
28 

38 
39 
28 
86 

387 
127 

145 

211 

40 

338 
16 

4 
105 

114 

10 

10 

40 

210 

223 

375 

42 

230 

182 

[5,  221 

26 

49 
210 

233 
249 

257 
258 
265 
272 
281 
286 
290 
291 
293 
299 
303 
304 
316 
316 
323 
325 
330 
336 
350 
360 
361 

14 
18 


428  INDEX. 

PAGE 

Ununited  fracture  of  lower  jaw  . 19 

Upper  jaw,  fractures  of '43 

,,  tumours  of  {see  Tumours) 

Vascular  sarcoma  of  upper  jaw 286 

Vasey,  Mr.,  deformity  of  jaw       .         .         .         .         .         .         .         -417 

Verneuil,  M. ,  on  closure  of  jaw 407 


Waeeen,  Dr.  Mason,  on  cysts  of  lower  jaw 
Weiss,  Mr.  F. ,  closure  by  cicatrix 
Wilkes,  Mr. ,  epithelioma  of  lower  jaw 
Wire  splint,  Hammond's 
Wiring  lower  jaw  .... 

Wounds  of  the  face      .... 


208 

357 

29 

40 

9 


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